
Class_ 
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COPYRIGHT DEPOSIT 



A 



PLATE I. 




Xeroderma Pigmentosum. 

(From a painting in oil.) 



L 



A PRACTICAL TREATISE 



DISEASES OF THE SKIN 



FOR THE USE OF 



STUDENTS AND PRACTITIONERS 



BY 

JAMES NEVINS HYDE, A.M., M.D. 

PROFESSOR OF SKIN, GENITO-URINARY, AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, 
CHICAGO; DERMATOLOGIST TO THE PRESBYTERIAN, AUGUSTANA, AND MICHAEL 
REESE HOSPITALS OF CHICAGO ; AND CONSULTING DERMATOLOGIST TO 
THE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN; 



FRANK HUGH MONTGOMERY, M.D. 

ASSOCIATE PROFESSOR OF SKIN, GENITO-URINARY, AND VENEREAL DISEASES, RUSH MEDICAL 
COLLEGE, CHICAGO ; PROFESSOR OF SKIN AND VENEREAL DISEASES, CHICAGO 
CLINICAL SCHOOL ; ATTENDING PHYSICIAN FOR SKIN AND VENE- 
REAL DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO 



SEVENTH AND EEVISED EDITION 



ILLUSTRATED WITH 107 ENGRAVINGS AND 34 PLATES IN COLORS 
AND MONOCHROME 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YORK 

1904 






LIBRARY <rf CONGRESS 
Two Oooies Received 

SEP 6 1904 
c Oooyrffht Entry 
**$ *, / 9 0<h 
CLASS CL *X°- Na 

f*M 



Entered according to Act of Congress, in the year 190±, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



ELECTROTYPED BY 
WESTCOTT St THOMSON, PHILADA. 



,-' 



TO 

JAMES CLARKE WHITE, M. D. 

PROFESSOR OF DERMATOLOGY 
HARVARD UNIVERSITY 

FIRST PRESIDENT OF THE 

AMERICAN" DERMATOLOGICAD ASSOCIATION 
THIS TREATISE IS 

WITH HIS PERMISSION 
INSCRIBED 



PREFACE TO THE SEVENTH EDITION. 



In the preparation of this edition every page has been subjected to 
a careful revision, much matter which was representative of its day 
has been eliminated, and more has been added to reflect the advances 
of the past three years. The engravings and plates have been similarly 
revised, many of the former figures having been replaced with newer 
and better illustrations, and still more have been added. Every effort 
has been made to secure clearness with conciseness, and so to accom- 
modate the material growth in the amount of information presented 
without exceeding the limits of a volume convenient for the hand. It 
is hoped that the work as it now goes forth may prove itself to be a 
trustworthy exponent of the science and practice of Dermatology in 
its most advanced state at the date of issue. 

The following new subjects have been introduced : General Pathol- 
ogy of the Skin, Radiotherapy and Phototherapy, Granulosis Rubra 
Nasi, Pyroplasmosis Hominis, Erythema Elevatum Diutinum, Ulcer- 
ating Granuloma of the Pudenda, the Psoriasiform Dermatoses 
(Parapsoriasis), Acrodermatitis Perstans, Dermatitis Vegetans, and 
Acrodermatitis Chronica Atrophicans. The important subjects of the 
technique and value in diseases of the skin of both the Finsen light 
and the X-rays have been considered fully, not only in a special 
chapter, but also in connection with the treatment of cutaneous Carci- 
noma, Tuberculosis, Acne Rosacea, Psoriasis, Lupus Erythematosus, 
and other disorders in which these measures have proved useful. 

Among the sections largely or wholly rewritten may be mentioned 
those devoted to Psoriasis, Dermatitis Exfoliativa, Pityriasis Rubra, 
Pityriasis Rubra Pilaris, Lichen Ruber, Lichen Planus, Ichthyosis, 
Elephantiasis, Acromegaly, Xeroderma Pigmentosum, the pathology 
and treatment of Cutaneous Tuberculosis, Erythema Induratum, the 



vi PREFACE TO THE SEVENTH EDITION. 

Dermatoses associated with Tuberculosis, Blastomycosis, Acrodynia, 
Pellagra, Oriental Sore, Phagedena Tropica, Piedra, and Verruga 
Peruana. 

The bibliographical references under each title have been carefully 
selected after an exhaustive review of the entire literature of Derma- 
tology. The object kept in view has been to furnish a key to the 
complete bibliography of each subject, the works cited being chiefly 
standard treatises or contributions to medical periodicals which are 
readily accessible. 

For the convenience of readers, both the apothecaries' and the 
metric systems of weights and measures, as in former editions, have 
been employed in the recommendation of remedies ; but it is to be noted 
that the parenthetical figures are approximate equivalents only. 

Our thanks are due to our Laboratory Assistant, Dr. Oliver S. 
Ormsby, for the new or revised sections on General Pathology, Radio- 
therapy, the Pathology of Cutaneous Tuberculosis, and the Dermatoses 
associated with Tuberculosis. We are also indebted to our associates, 
Drs. E. L. McEwen and W. L. McBride, for valuable services rendered 
while the edition w T as passing through the press. 

J. N. H. 

F. H. M. 

Chicago, August, 1904. 



CONTENTS 



PAGE 

Anatomy and Physiology of the Skin 17 

General Symptomatology 52 

General Etiology 64 

General Pathology 71 

General Diagnosis 77 

General Prognosis 87 

General Therapeutics 89 

Classification 122 



DISEASES OF THE SKIN. 

CLASS I. 
DISORDERS OE THE GLANDS. 

1. Of the Sweat-glands 125 

Hyperidrosis 125 

Sudamen 129 

Miliary Eever 131 

Hydrocystoma 131 

Granulosis Rubra Nasi 133 

Anidrosis 133 

Bromidrosis 134 

Chromidrosis 136 

Uridrosis 138 

Hsematidrosis 139 

2. Of the Sebaceous Glands 140 

Seborrhoea 140 

Asteatosis 152 

Comedo 153 

Milium 158 

Steatoma ' 161 

Congenital Fibro-sebaceous Disease 163 

CLASS II. 

INFLAMMATIONS. 

Exanthemata 165 

Morbilli 165 

Rotheln 169 

Scarlatina 171 

Variola 176 

Varicella 186 

Vaccinia 188 

Erythma 193 

Symptomatic Erythema 195 

Erythema Scarlatiniforme 197 

vii 



viii CONTENTS. 

PAGE 

Erythema Pernio 199 

Erythema Intertrigo 200 

Erythema Multiforme ... 203 

Herpes Iris 204 

Erythema Nodosum 205 

Acrodynia , 209 

Pyroplasmosis Hominis 211 

Erythema Elevatum Diutinum 212 

Pellagra 213 

Urticaria , 215 

Urticaria Pigmentosa 223 

Angioneurotic (Edema 226 

Dermatitis 228 

Traumatica 228 

Venenata 228 

Calorica 232 

Congelatio , 234 

Medicamentosa 235 

Feigned Eruptions 246 

X-Ray Dermatitis 247 

Gangrenosa 248 

Symmetrical Gangrene, etc. (Raynaud's Disease) 251 

Erysipelas 252 

Erysipeloid . 257 

Furunculus . 258 

Carbunculus 261 

Anthrax 264 

Equinia 266 

Dissection-wounds and Animal Poisons 268 

Oriental Sore 269 

Ulcerating Granuloma of the Pudenda 271 

Phagedena Tropica 272 

Phlegmone Diffusa . 274 

Sycosis 275 

Impetigo 282 

Contagiosa 284 

Ecthyma 287 

Conglomerate Pustular Perifolliculitis 290 

Folliculitis and Perifolliculitis 290 

Herpes Simplex . 291 

Herpes Zoster 295 

Dermatitis Herpetiformis 302 

Pompholyx . . . 306 

Psoriasis 308 

Pityriasis rosea 329 

Dermatitis Exfoliativa 332 

Dermatitis Exfoliativa Infantum 335 

Pityriasis Rubra 336 

Pityriasis Rubra Pilaris 339 

Epidemic Exfoliative Dermatitis . 342 

Psoriasiform Dermatoses 344 

Lichen Ruber 347 

Lichen Planus 348 

Lichen Annularis 355 



CONTENTS. ix 

PAGE 

Lichenification , 355 

Eczema 356 

Topical and Special Varieties 403 

Of Children 403 

Of the Scalp 404 

Of the Face , 406 

Of the Lips 408 

Cheilitis Glandularis, etc 409 

Of the Nostrils 410 

Of the Ears 411 

Of the Eyelids 412 

Of the Beard 413 

Of the Genital Organs 414 

Of the Anus and Anal Region 417 

Of the Nipple and Breast of Women 419 

Of the Umbilicus 420 

Of the Legs 421 

Of the Hands and Eeet 422 

Of the Nails 426 

Universal ' 426 

Of the Tropics 427 

Eczema Sehorrhoeicum 428 

Dermatitis Bepens 434 

Prurigo 435 

Acne 439 

Acne Rosacea 453 

Acne Varioliformis 459 

Impetigo Herpetiformis -461 

Pemphigus 462 

Acute 463 

Neonatorum 465 

Chronic 465 

Foliaceus 467 

Of Young Girls 469 

Vegetans 469 

Dermatitis Vegetans 471 

Hydroa \ T acciniforme 477 

iEstivale . . . • 478 

Epidermolysis Bullosa Hereditaria 479 

CLASS III. 

HAEMORRHAGES. 

Purpura 481 

Simplex 482 

Rheumatica 483 

Hemorrhagica 484 

Scorbutica 484 

CLASS IV. 
HYPERTROPHIES. 

Lentigo 487 

Chloasma 488 



X CONTENTS. 

PAGE 

Anomalous Discoloration 491 

Keratosis . 494 

Pilaris 494 

Senilis 497 

Follicularis 498 

Keratodermia Palmaris et Plantaris 501 

Angiokeratoma 503 

Keratosis Follicularis Contagiosa 504 

Hyperkeratosis Striata et Follicularis 504 

Parakeratosis Scutularis 505 

Porokeratosis 505 

Molluscum Epitheliale 506 

Callositas 510 

Clavus 511 

Cornu Cutaneum 513 

Verruca 515 

Multiple Cutaneous Tumors, Pruritic 521 

Synovial Lesions of the Skin 522 

Papilloma 522 

Nsevus Pigmentosus . . . 523 

Linear Nsevus 523 

Acanthosis Nigricans 526 

Ichthyosis 527 

Congenita « 530 

Linguae 530 

Onychauxis 534 

Paronychia 535 

Hypertrichosis 537 

Neurotica 539 

Plica Polonica 539 

Neuropathic Plica 539 

(Edema Neonatorum 544 

Sclerema Neonatorum 546 

Scleroderma 547 

Morphoea 549 

Hemiatrophia Facialis 551 

Elephantiasis 555 

Lymph-scrotum 557 

Acromegaly 561 

CLASS V. 

ATROPHIES. 

Leucoderma 563 

Albinismus 564 

Vitiligo 565 

Canities 568 

Alopecia 570 

Congenitalis • 570 

Alopecia Senilis 571 

Prematura 572 

Furfuracea 573 

Areata 576 

Follicularis 585 



CONTENTS. xi 

PAGE 

Keloid-Acne 589 

Ulerythema Aphryogenes . . 589 

Atrophia Pilorum Propria 591 

Fragilitas Crinium 592 

Trichorrhexis Nodosa . . 593 

Monilethrix 595 

Nodose Swellings of Shafts of Hair 595 

Expansions and Fissures of Hairs 595 

Lepothrix 596 

Piedra 597 

Beigel's Disease 598 

Tinea Nodosa 598 

Atrophia Unguis 598 

Achromia Unguium 599 

Atrophia Cutis 600 

Senilis 600 

Maculosa et Striata 601 

Diffuse, Idiopathic 602 

Acrodermatitis Chronica Atrophicans 602 

Partial Symptomatic 603 

Glossy Skin 603 

Blanching Atrophy of Skin 604 

Multiple Benign Tumor-like New-growths 604 

Kraurosis Vulvae 605 

Perforating Ulcer of the Foot 605 

Morgan's Disease 607 

Ainhum 608 



CLASS VI. 
NEW-GKOWTHS. 

Cicatrix 611 

Keloid 613 

Cicatricial Keloid . . . . 615 

Fibroma 617 

Dermatolysis 619 

Neuroma 621 

Xanthoma 623 

Xanthoma Diabeticorum 628 

Colloid Metamorphosis of the Skin 630 

Adenoma of the Sebaceous Glands 631 

Coil-glands . 632 

Multiple Benign Cystic Epithelioma 633 

Lymphangioma Tuberosum Multiplex 634 

Leukeratosis Buccalis . 634 

Myoma 637 

Angioma 638 

Angioma Nsevus Yasculosus ; 638 

Telangiectasis • . 639 

Cavernosum 640 

Serpiginosum 643 

Lymphangioma . . 644 

Circumscriptum 645 



xii CONTENTS. 

PAGE 

Xeroderma Pigmentosum 647 

Rhinoscleroma . , 651 

Tuberculosis Cutis 653 

1. Lupus Vulgaris 653 

2. Tuberculosis Cutis Verrucosa 658 

A. Verruca Necrogenica 658 

B. Tuberculosis Verrucosa Cutis 659 

C. Other Verrucous Tuberculoses 660 

3. Tuberculosis Cutis Orificialis 661 

4. Scrofuloderma 662 

Tuberculous Dactylitis 663 

Suppurative Tubercular Lymphangiectasis 663 

Tuberculosis Cutis Serpiginosa 664 

Lymphangitis Tuberculosa Cutanea 664 

5. Dermatoses, probably Tubercular 676 

Lichen Scrofulosorum • • . 676 

Erythema Induratum 678 

Dermatosus associated with Tuberculosis 679 

Tuberculides 679 

Acnitis . 681 

Folliclis 681 

Lupus Erythematosus 683 

Syphilis ' 693 

Chancre 695 

Syphilodermata 698 

Syphiloderma Maculosum 702 

Papillosum 706 

Vesiculosum 712 

Pustulosum 713 

Bullosum 716 

Tuberculosum 717 

Serpiginosum 717 

Gummatosum 720 

Erythanthema Syphiliticum 722 

Syphilis of Mucous Surfaces 723 

Syphiloderma Infantile, Acquisitum et Hsereditarium 725 

Chancroid 750 

Lepra . , 755 

Tuberosa 757 

Maculosa 759 

Ansesthetica ... 760 

The Sartian Disease 769 

Frambesia 769 

Verruga Peruana 771 

Mycosis Fungoides 773 

Sarcoma Cutis - 780 

A.. Melanotic Sarcoma 780 

B. Primary Non-melanotic Sarcoma 781 

Sarcoid Growths - 782 

Idiopathic Multiple Pigment Sarcoma . 782 

Carcinoma 786 

Epithelioma 786 

Superficial, or Discoid . 787 

Rodent Ulcer 787 



CONTENTS. xiii 

PAGE 

Deep 788 

Papillary • 789 

Cancer of the Head 790 

Lower Lip 791 

Genital Organs 791 

Extremities 791 

Mucous Surfaces 791 

Paget's Disease 799 

Cancer of Connective Tissue 800 

en Cuirasse 801 

Tuberose Carcinoma 802 

Melanotic Carcinoma 802 

Endothelioma 803 



CLASS VII. 
SENSORY DERMATO-NEUROSES. 

Hyperesthesia 805 

Dermatalgia 806 

Anaesthesia 808 

Paresthesia 808 

Pruritus 809 

Hiemalis 817 

Prairie Itch 817 

Myxcedema 819 

CLASS VIII. 
PAKASITIC AFFECTIONS. 

Disorders due to Vegetable Parasites . 823 

Tinea Favosa 823 

Favus of the Nail 825 

Tinea Trichophytina 831 

Tinea Circinata 833 

Eczema Marginatum 835 

Tinea Trichophytina Unguium 836 

Tinea Tonsurans 840 

Tinea Kerion 847 

Tinea Sycosis 848 

Precautions in Tinea Favosa and Trichophytina 853 

Tinea Imbricata 854 

Dhobie Itch 856 

Tinea Versicolor 856 

Erythrasma .' 860 

La Perleche '. .... 862 

Myringomycosis 863 

Pinta 863 

Mycetoma 865 

Actinomycosis of the Skin 870 

Blastomycosis of the Skin 873 

Protozoic and Coccidioidal Infections 881 

Refractory Subcutaneous Abscesses caused by Sporothrix 881 



xiv CONTENTS. 

PAGE" 

Diseases due to Animal Parasites . 881 

Scabies 882 

Demodex Folliculorum . 892 

Pulex Penetrans 892 

Irritans 893 

Pilaria Medinensis . . . 894 

Craw-Craw 896 

Cysticercus Cellulosse Cutis 897 

Echinococcus 898 

Distoma Hepaticum 898 

Leptus 898 

Dipterous Larvae in the Skin • 900' 

Ixodes 901 

Pediculosis 902 

Capillitii 902 

Corporis 905 

Pubis 908 

Vagabond's Disease 910 

Pediculi and Acari from Lower Animals 910* 

Cimex Lectularius 911 

Culex Pipiens 912 

Protozoa and Sporozoa 913. 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Section of skin from the palm of the hand 18 

2. Subcutaneous fat-tissue 21 

3. Columnae adiposae 22 

4. Vertical section of skin after injection (from beneath) with Berlin blue 23 

5. Vascular and nervous papillae 24 

6. Scalp of a colored man — horizontal section 25 

7. Prickle-cells 26 

8. Pacinian body, after silver staining 32 

9. Section of papilla containing a tactile body (from the skin of a finger) 33 

10. Transverse section of nervous papilla 34 

11. Section of hair-follicle during the formation of a new hair 38 

12. Hair-follicle in longitudinal section 38 

13. Lower portion of hair-pouch from the lip of a kitten . 40 

14. Transverse section of hair and follicle 41 

15. 16. Sebaceous glands of the second class from the alas of the nose . 43 

17. Coil of a sweat-gland 44 

18. A sweat-pore traversing the epithelial layers of the skin 45 

19. Section of skin from the palm of the hand 46 

20. Thin section of the skin of the finger removed at the site of a 

sweat-pore 48 

21. Vertical section of one-half of nail and matrix 49 

22. Implantation of the nail at its border 51 

23. Irido-platinum needle 112 

24. Milium needle 112 

25. Scarifying-spud 112 

26. Epilating-forceps . 113 

27. Piffard's grappling-forceps 113 

28. Piffard's cutisector 113 

29. 30. Dermal curettes 113 

31. Hess's glass pleximeter ' 113 

32. Comedo-extractor 113 

33. Cutaneous punch 113 

34. Massering-ball 113 

35. Section of a comedo 155 

36. Vertical section of pustule at the beginning of pustulation in variola . 178 

37. Vertical section of one-half of an undeveloped pustule 180 

38. Autographism in urticaria 216 

XV 



xvi LIST OF ILLUSTRATIONS. 

FIG. PAGE 

39. Urticaria pigmentosa 224 

40. Arsenical pigmentation and keratosis 237 

41. Papilloma due to ingestion of the iodine compounds 241 

42. Feigned eruption 247 

43. Dermatitis gangrenosa infautum 250 

44. Anthrax bacilli 265 

45. Lupoid sycosis 277 

46. Staphylococcia 283 

47. Acne necrotica 459 

48. Acute pemphigus 464 

49. Hydroa vacciniforme - 477 

50. Molluscum epitheliale 507 

51. Molluscous corpuscles 508 

52. 53. Cutaneous horns 514 

54. Vertical section of the summit of a pointed wart 519 

55. Nsevus linearis 524 

56. Ichthyosis hystrix 528 

57. Ichthyosis hystrix, vertical section 529 

58. The Russian " dog-faced man " 537 

59. Scleroderma with ulceration 548 

60. Elephantiasis of the foot and leg ..." 556 

61. Elephantiasis scroti 556 

62. Vitiligo in a negro boy 566 

63. Alopecia areata 577 

64. Lupoid sycosis 588 

65. Congenital atrophy of hair 591 

66. Trichorrhexis nodosa 593 

67. Keloid 614 

68. Neuroma of the skin ; external appearance 621 

69. Microscopic structure of neuroma 622 

70. Lupus vulgaris 654 

71. Tuberculosis verrucosa cutis 659 

72. Lupus erythematosus of the face 684 

73. Chancre of the tongue 696 

74. Facial cicatrices following tubercular syphilodermata after twenty- 

five years of infection 701 

75. Vegetating condylomata of the anus 709 

76. Corymbose papular syphiloderm 711 

77. Ulcerative tubercular syphiloderm 718 

78. Syphiloma of the vulva with gummatous changes in labia and clitoris . 720 

79. Lepra tuberculosa 756 

80. Tubercular leprosy , 757 

81. Anaesthetic leprosy with mutilating results 761 

82. Larynx of patient affected with lepra tuberculosa 764 

83. Bacilli of leprosy 765 



LIST OF ILLUSTRATIONS. xvii 

FIG. PAGE 

84. Mycosis fungoides 776 

85. Sarcoma 785 

86. Epithelioma, vertical section 793 

87. Cancer en cuirasse 801 

88. Acliorion Schonleinii 826 

89. Epidermis invaded by trichophyton 837 

90. Hair invaded by trichophyton 843 

91. Filaments and spores of trichophyton from the beard 850 

92. Microsporon furfur 858 

93. Microsporon minutissimum 861 

94. Osseous lesions in mycetoma 867 

95. Female acarus 883 

96. Acarian furrow 884 

97. Demodex folliculorum • , 892 

98. Leptus Americanus 899 

99. Leptus autumnalis 899 

100. Rouget 899 

101. (Estrus 900 

102. Larvae from body of child 900 

103. Pediculus capillitii 903 

104. Ova of head-louse 903 

105. Pediculus corporis 905 

106. Pediculus pubis 909 



LIST OF PLATES. 



Plate I. 


Plate II. 


Plate III. 


Plate IV. 


Plate V. 


Plate VI. 


Plate VII. 


Plate VIII. 


Plate IX. 


Plate X. 


Plate XI. 


Plate XII. 


Plate XIII. 


Plate XIV. 


Plate XV. 


Plate XVI. 


Plate XVII. 


Plate XVIII. 


Plate XIX. 


Plate XX. 


Plate XXI. 


Plate XXII. 


Plate XXIII. 


Plate XXIV. 


Plate XXV. 


Plate XXVI. 


Plate XXVII. 


Plate XXVIII. 


Plate XXIX. 


Plate XXX. 


Plate XXXI. 


Plate XXXII. 


Plate XXXIII. 


Plate XXXIV. 



Xeroderma Pigmentosum frontispiece 

Erythema Multiforme, Circinate type . . . .facing page 203 

Dermatitis Herpetiformis facing page 303 

Psoriasis . facing page 310 

Pityriasis Rosea facing page 329 

Pityriasis Eubra Pilaris facing page 339 

Acne-keloid of the Back facing page 442 

Purpura due to Copaiba facing page 482 

Keratosis Punctata facing page 501 

Palmar Keratosis due to Arsenic facing page 502 

Congenital Warts facing page 516 

Naevus Lipomatodes facing page 523 

Syphilis of the Nails facing page 535 

Circumscribed Scleroderma facing page 549 

Elephantiasis Telangiectodes of the Upper 

Lip and Portions of the Face facing page 555 

Malum Perforans Pedis, with Symmetrical 
Keratoma of the Palms and Soles .... facing page 605 

Multiple Fibroma of the Back facing page 617 

Fibroma Pendulum facing page 619 

Xanthoma facing page 623 

Xanthoma Tuberosum of Hands facing page 624 

Xanthoma Multiplex facing page 625 

Xanthoma Diabeticorum facing page 628 

Lupus Hypertrophicus facing page 655 

Annular Papular Syphiloderm facing page 708 

Large Pustulo-crustaceous Syphiloderm of 

the Scalp and Body facing page 715 

Tubercular Syphiloderm, Resolutive and Ser- 
piginous . facing page 717 

Prefungoid Stage of Mycosis Fungoides . .facing page 774 

Cutaneous Carcinoma facing page 1 '87 

Cutaneous Carcinoma facing page 789 

Microsporon Audouini and Megalosporon 

Endothrix, X 500 facing page 832 

Mycetoma facing page 865 

Blastomycosis of the Skin facing page 873 

Blastomycosis of the Skin facing page 875 

Histological and Bacteriological Features of 
Blastomycosis facing page 877 



ABBREVIATIONS EMPLOYED IN THE WORK 



Annales : Annales de Dermatologie et de Syphiligraphie, Paris. 

Archiv : Archiv fur Dermatologie und Syphilis, 1869-73 ; and since 1889. 

Brit. Jour. Derm. : British Journal of Dermatology, London. 

Centralbl. : Dermatologisches Centralblatt, Leipzig. 

Giorn. ital. : Giornale italiano delle malattie veneree e della pelle, Milan. 

Jour. Cutan. Dis. : Journal of Cutaneous and Venereal Diseases, 1882-87 ; Journal 
of Cutaneous and Geni to-Urinary Diseases, 1888-1902 ; Journal of Cutaneous Diseases, 
including Syphilis, since 1903, New York. 

Jour. mal. cutan. : Journal des maladies cutan£es et syphilitiques, Paris. 

Monatshefte : Monatshefte fur praktische Dermatologie, Hamburg. 

Vierteljahr. : Vierterjahresschrift fur Dermatologie und Syphilis, 1874-88. 

Zeitschrift: Dermatologische Zeitschrift, Berlin. 

Allbutt's System : A System of Medicine by Many Writers, edited by T. C. Allbutt, 
New York, 1901. 

American Text-book : An American Text-book of Genito- Urinary Diseases, Syphilis 
and Diseases of the Skin, edited by L. Bolton Bangs and W. A. Hardaway, Phila- 
delphia. 

Besnier's and Doyon's Notes : Besnier's and Doyon's notes in their French trans- 
lation of Kaposi's treatise. 

Crocker, Diseases of the Skin : Diseases of the Skin, by Badcliffe-Crocker, third edi- 
tion, Philadelphia, 1903. 

Duhring, Cutaneous Medicine: Cutaneous Medicine, Parts I. and II., by Louis 
Duhring, Philadelphia, 1896. 

Internat. Atlas : The International Atlas of Kare Diseases of the Skin. 

Jarisch, Die Hautkrankheiten : Die Hautkrankheiten, Nothnagel's Specielle Path- 
ologie und Therapie XXIV., Vienna, 1900 u. 1901. 

Kaposi, Diseases of the Skin : Pathologie und Therapie der Hautkrankheiten, ninth 
edition, 1899. 

La Pratique Dermatologique : La Pratique Dermatologique, Traite de Dermatologie 
appliquee, edited by E. Besnier, L. Brocq, and L. Jacquet, Paris, 1900-1902. 

MacLeod, Pathology : Practical Handbook of the Pathology of the Skin, by J. M. 
H. MacLeod, London and Phila., 1903. 

Manson, Tropical Diseases, by Patrick Manson, London, 1900. 

Morrow's System : A System of Genito-urinary Diseases, Syphilology, and Derma- 
tology ; edited by Prince A. Morrow, New York, 1894. 

Mracek, Handbuch: Handbuch der Hautkrankheiten, edited by Franz Mracek, 
Vienna, 1901-1903. 

Scheube, Diseases of Warm Countries : Diseases of Warm Countries, by B. Scheube, 
translated by Pauline Falcke, edited by James Cantlie, Phila., 1903. 

Stelwagon, Diseases of the Skin : Treatise on Diseases of the Skin, Henry W. Stel- 
wagon, Phila. and London, 1902. 

Twentieth Century Practice: Twentieth Century Practice of Medicine, edited by 
Thomas L. Stedman, New York, 1896. 

L T nna, Histopathology : The Histopathology of the Skin, P. G. Unna ; English 
translation by Norman Walker, Edinburgh and New York, 1896. 



I. ANATOMY AND PHYSIOLOGY OF 

THE SKIN. 1 



The skin is the living envelope of the human body ; it is closely 
associated Avith underlying structures, and by its situation is brought 
into intimate relation also with the external world. The skin is a 
complex, elastic, and sensitive organ, varying greatly in different con- 
ditions of climate, age, sex, health, and race ; and varying also in the 
characteristics exhibited in different localities upon the same indi- 
vidual. Thus, in color there is a wide range between the fair skin of 
the blonde and the black skin of the negro, between the rosy pink of 
the infant's palm and the dark-brown hue of the genital region of the 
aged. The skin varies also in pliability and thickness, being delicate 
and lax over the eyelids, the lips, and the prepuce ; and much thicker 
and more firmly attached over the palms and the soles. 

The appearance of the skin, even in conditions of health, changes 
within appreciable limits. It is the exposed parts (such as the face) 
which the eye of the physician most frequently searches, and which 
betray evidence of mental emotions, physiological fluxes, sedentary or 
active habits of life, and fatigue or unusual conditions of vigor. 

Viewed externally, the skin is seen to be traversed by superficial 
and deeper furrows, dotted with numerous depressions representing the 
mouths of its follicles, at the digital extremities protected by the nails, 
and provided very generally with coarse or with fine, downy hairs, 
which in some parts are of sufficient growth to conceal the skin from 
view. This pilary growth serves not merely as an ornament of the 
body, but also as a protection to some of its regions most sensitive to 
thermal changes. 

By its extraordinary sensitiveness to different degrees of tempera- 
ture and to the physical properties of the bodies with which it is 
brought into contact the skin becomes, even when unaided by the eye, 
a valuable means of preserving the human frame from external in- 
jury. This protective function is, in part, due to the horny character 
of its outer layer, as a consequence of which the loss of essential fluids 
and the ingress of noxious substances are equally restricted. 

One of the most important functions of the skin is the part it 
plays in regulating the body-temperature. The temperature-variations 
at its surface, modified naturally by the character and quantity of the 

1 For further details regarding the anatomy and physiology of the skin, the reader 
is referred to Duhring, Cutaneous Medicine, vol. i., pp. 1-71 (bibliography) ; Rabl and 
Kreidl, Mracek, Handbuch, Bd. i., pp. 1-266 (complete bibliography) ; Darier, La 
Pratique Dermatologique, t. i., pp. 7-59; Unna (translation by W. T. Alexander), 
Ziemssen's Handbook of Skin Disease, pp. 1-66. 

2 17 



18 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



clothing when such is worn, produce corresponding variations in the 
smooth muscles and contractile blood-vessels of the skin. By enlarge- 
ment or diminution of the lumen of these vessels, whether resulting 



Fig. 1. 




Section of skin from the palm of the hand, magnified 150 diameters : a, stratum corneum ; 
a', its superficial layer ; b, stratum lucidum ; c, stratum granulosum ; d, stratum mucosum rrete) ; 
e, pars papillaris of the corium, loops of capillary vessels showing in vascular papillae : f, pars 
reticularis of the corium, showing coarse interlacing connective-tissue bundles; g, transverse 
section of the latter; h, double-contoured nerve-fibres passing to tactile body; i, coil-glands ; 
k, ducts of coil-glands: 1, sweat-pores passing to surface of the epidermis; m, arteries of the 
skin terminating in capillaries ; n, veins of the skin forming plexuses: o, fat-cells, encompassed 
by capillary loops, in relation with coil-glands (the capillaries of the latter are purposely omitted 
in the drawing) ; p, obliquely and transversely divided bundles of connective-tissue fibres of the 
corium and subcutaneous tissue. 



ANATOMY. 19 

directly from the action of heat or of cold at the surface, or indirectly 
through an effect upon the vasomotor centres, large quantities of blood 
are brought to or removed from the superficies of the body. In one 
case the blood is cooled by evaporation at the body-surface ; in the 
other, the loss of heat by such evaporation is greatly restricted. This 
process is materially influenced by acceleration or retardation of the 
heart's action, whether produced by psychical or by physical causes. It 
is also modified by the occurrence of sweating, as a result of which heat 
in varying amounts is rendered latent, and either watery vapor escapes 
from the surface or sweat is exuded in drops, the aggregate of which 
may be several pounds in weight in the course of twenty-four hours. 

To a limited degree the skin is capable of acting as a respiratory 
agent, eliminating carbonic acid gas with watery vapor, and possibly 
also absorbing oxygen in small amount. Its power of absorbing ali- 
ments, medicaments, and toxic substances has as yet but imperfectly 
been determined. Substances in a liquid state are practically not 
absorbed so long as the horny layer of the epidermis is intact. With 
this layer intact minute particles of matter have been conveyed to 
the deeper structures in the operations of skiagraphy, of cataphoresis, 
and of dielectrolysis. The actual loss, however, of this external 
protective layer permits the ready absorption of many liquids. Gases 
may be absorbed by the unbroken skin, and to a less extent are some 
fats and oils, as well as a few substances in a finely powdered state. 
Such absorption, when it occurs, is probably effected through the 
portal of a hair-follicle and the ducts of the cutaneous glands. 

The skin is provided with a natural unguent, by which, in a state 
of health, it is constantly anointed. The fatty and oily secretions of 
the skin are concerned not merely in the anointing of the general sur- 
face and of the hairs, but also in the regulation of the body-tempera- 
ture and in the prevention of maceration of the tissues by the sweat. 

The complex organ called the skin is essential to the life of the 
individual. The sexual, and possibly other, organs of the human 
body may have their functions arrested, or they may even be obliter- 
ated by destructive processes, and life still continue ; but if all the 
functions of the skin were suspended for a sufficient period of time 
the result would be fatal to human life. In its relations alone to 
the complicated processes by which the heat of the body is main- 
tained at a relatively fixed standard the skin exhibits its impor- 
tance to the general economy. It is thus seen to be, not an isolated 
membrane stretched mechanically over an artificial machine, but is one 
of several living and potential systems of the body, each system being 
in intimate union with all others. 

Development of the Skin. 1 — The corium is developed in intra- 
uterine life from the superficial layer of the mesoblast (the " skin-plate " 
of Remak). Its lower portions become first visible in a myxofibrous 
structure, which between the seventh and eighth months is replaced by 
a collagenous substance, from which the bundles of connective tissue 
develop, finer fibrillae becoming later elastic fibres. 

1 For detailed description, with illustrations, see MacLeod. Brit. Jour. Derm., 1898, 
x., pp. 183 and 221. 



20 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The epidermis springs from the ectoderm, and has therefore no 
primary histological relation with the corium, though at about the fourth 
month it is projected upon the papillary layer so as to give rise to the 
grooves and interdigitations which produce in the skin of the adult 
an important and intimate connection between the two. 1 At first a 
single layer, later two, three, and more rows of prickle-cells develop 
up to the fifth month, the horny covering persisting up to the seventh 
month merely as a thin stratum composed of but two rows of cells. 
The appendages of the skin are mostly developed between the sixth 
and eighth months. 

The integument of the body, when studied with the aid of the micro- 
scope, is found to be composed of several organic parts, which are : the 
subcutaneous connective tissue (the hypoderm), resting on the deeper 
structures of the body ; then, more externally, the corium, or true 
skin ; lastly, an outermost coat, the epidermis, or cuticle. Beside 
these parts, the skin contains coil-glands, sebaceous glands, hairs, nails, 
blood-vessels, lymph-vessels, muscles, pigment, and nerves. It will 
be instructive to study the deeper parts of the skin before considering 
those more superficially disposed, as their mutual relations will thus 
be made clearer. 



SUBCUTANEOUS TISSUE (STRATUM SUBCUTANEUM). 

The subcutaneous tissue, or hypoderm, is differentiated from the 
corium between the third and the fourth month of foetal life. It 
is a structure serving a mechanical purpose as a receptacle for fat, and 
for the support of vessels and nerves passing from the tissue beneath 
to the corium which lies next above it. It contains, also, coil-glands, 
some of the hair-follicles more deeply seated than their fellows, and 
Pacinian corpuscles. There is no distinct boundary-line between the 
upper limits of the subcutaneous tissue and the overlying corium, to 
which it projects columnar masses of fat, extending obliquely to the 
coil-glands and the hair- follicles above, often with lateral, horizontally 
disposed prolongations of similar shape. It is built up of loose con- 
nective-tissue bundles, prolonged from the aponeuroses, fasciae, and the 
membranes lying beneath. 

The subcutaneous tissue is attached firmly to the skin over the 
extensor surfaces of the articulations, the palms and soles, and the 
groins by short, coarse bundles, between which are single or multi- 
locular spaces lined with endothelia secreting a mucoid fluid. These 
spaces are the Bursae Mucosae. Elsewhere, as in the eyelids, the penis, 
the scrotum, and the auricle of the ear, the attachment to the skin is 

1 The researches of Leo Loeb (Archiv. f. Entwicklungsmechanik d. organ., 1897, 
vi., p. 1), and of Alexander Maximow (" Experimentelle Untersuchungen iiber die 
Entziindliche Neubildung von Bindegewebe," Ziegler's Beitrage, Suppl. v.) show, how- 
ever, that cells indistinguishable from epithelial cells may develop from the mesoderm. 
Kromayer (Archiv, 1902, lxii., p. 299) states that connective tissue may originate in 
epithelial cells, and he believes the corium is derived from the basal layer of the rete. 
He has, however, few supporters in these views. Of. MacLeod, Brit. Jour. Derm., 1903, 
xv., p. 257. 



THE CORIUM. 



21 




by loose, delicate connective tissue containing no fat-globules. All other 
fibrous tracts are arranged obliquely ; they admit, by their extension, 
of various degrees of pliability, 
and inclose rhomboidal spaces con- 
taining more or less numerous fat- 
globules. These spaces are tab- 
ulated, are bounded by a delicate 
fibrous connective tissue, and are 
supplied abundantly with blood- 
vessels. This layer is termed the 
Panniculus Adiposus. 

The deposit of fat in the body 
is reduced greatly in all diseases 
productive of emaciation, but 
never wholly disappears during 
life. In cases of obesity, fat is 
deposited in excess of normal 
limits, and it may then be con- 
cerned in the production or the 
aggravation of disease. It is due 
largely to the greater or lesser vol- 
ume of the panniculus adiposus 
that the natural outlines of the 
body are made to the eye graceful 
and attractive, or the reverse. 

Columnae Adiposae (Fat- 
columns of Warren). — These 
are columnar prolongations from 
the adipose tissue of the paninculus 

adiposus below, passing in nearly vertical position to the bases of the 
hair-pouches, especially conspicuous in the thickened integument of 
the back, the neck, and the shoulders. The columnar axes are more or 
less parallel with the erectores pilorum muscles, and aid in supporting 
the coil-glands and the blood-vessels and lymphatic vessels. The 
cones fibreux of the French are cone-shaped masses of connective tissue 
which extend from the lower borders of the corium, and which pene- 
trate for a space into the adipose tissue. The part which these com- 
ponents of the skin play in the formation of carbuncle is set forth in 
that connection. 

THE CORIUM. 

The corium (Derma, Cutis, Cutis Vera, or True Skin) is com- 
posed of bundles of fibres of connective tissue, the decussations of which 
produce a dense felt-work, coarsest toward the subcutaneous tissue 
upon which it rests inferiority, and finest in the outermost portion 
which is in contact with the epidermis above. The bundles are com- 
posed chiefly of fibres of white fibrous tissue, but are accompanied by 
a varying number of elastic fibres. Connective-tissue corpuscles, vacuo- 
lated cells (Schapfer), and mast-cells are present in varying numbers. 1 
1 See section on General Pathology. 



having 
>sof 



Subcutaneous fat-tissue, the fat 
been extracted with turpentine : B, bundle? 
fibrous connective tissue, carrying injected 
blood-vessels ; C, capsules of fat-globules, 
with oblong nuclei. Magnified 500 diameters. 
(After Heitzmann.) 



22 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



There is a "cement-substance," or basis-substance, surrounding all 
the fibres and holding the various elements of the skin together. 
The derma is rich in blood-vessels and capillaries, especially in the 
papillary layer, and contains many nerves, nerve-endings, and terminal 
nerve-organs. It further contains lymphatics, smaller muscle-fibres, 
hairs, sweat-glands, and sebaceous glands. Its thickness varies greatly 
with different individuals and at different ages. It is thinnest in the 
infant, and on the eyelids, the prepuce, and the inner surfaces of the 
labia majora. It is thickest in vigorous adults, and over the back, the 
buttocks, the palms, and the soles. 

The bundles of the connective tissue of the derma accompany all 
elongations of an epithelial character. They produce the follicles 
around the root-sheaths of the hair, the capsules around the coil- 
glands, and the layers which surround their ducts. 

Corresponding with their anatomical structure the upper and lower 
portions of the derma are called respectively the " papillary layer " and 
the " reticular layer." There is no sharp dividing-line between these 
layers, the pars reticularis passing gradually into the pars papillaris 
above and into the subcutaneous tissue below. 

Cleavage of the Skin. — The fibres and bundles of connective 
tissue in the skin are arranged according to a definite plan. Puncture 



Fig. 3. 




Vertical section of the skin showing : a, epidermis; b, erector pih muscle; d, column ae adi- 
posse ; c, coil-gland suspended in the columnee adiposse ; h, sebaceous gland ; p, horizontal 
prolongations of the column ; /, fibrous bundles of the corium ; g, panniculus adiposus ; k, band 
of fibrous tissue extending into the panniculus adiposus. (After Warren.) 

of the integument with a sharp and well-rounded instrument is pro- 
ductive not of a circular opening, but of a longitudinal slit. The 
extensibility and retractive power of the skin are largely dependent 
upon the arrangement of these fibres. 

Pars Reticularis. — The reticular layer of the corium is made up, 



THE CORIUM. 23 

as has been seen, of interlacing connective-tissue bundles, with inter- 
spaces increasingly larger from without inward. The fineness of the 
bundles decreases, in the same way, from within outward, being finest 
where the minute papillae of the corium project into the rete, and 
coarsest near the subcutaneous tissue. 

Pars Papillaris. — The papillary layer of the corium lies in con- 
tact with the rete above, and is connected below with the deeper retic- 
ular portion of the true skin. Between the rete and the papillae of 
the derma a hyaline substance is interposed, which is supposed to be 
identical with the cement-substance surrounding and separating the 
fibrillar of the corium. The basal membrane once thought to be 
stretched between the rete mucosum of the epidermis and the papillary 
layer of the corium cannot be demonstrated to exist. 

Viewed obliquely with an amplification of about three hundred 
diameters, it will be seen that long and slender filaments from the 
prickle-cells of the mucous layer of the epidermis encircle in a spiral 
direction both nervous and vascular papillae. At the apices of the 
latter these threads completely surround the connective-tissue fibres. 

The name of this portion of the derma is intended to describe its 
chief characteristics, the existence of numerous digital prolongations or 
nipple-like prominences of the corium, made up of delicate connective- 

Fig. 4. 




A^ertical section of skin after injection (from beneath) of areolar tissue with Berlin blue: 
a, epidermis ; /, corium ; g, panniculus adiposus ; h, sebaceous gland. (After Warren.) 

tissue fibres which do not interlace and which are abundantly provided 
with nuclei. The papillae spring each from a single, or several from a 
common, ovoid base ; their bulbous, conical, or blunt apices reach into 
the rete, which also dips down between them in prolongations termed 
" rete-pegs." The papillae vary in size in different parts of the body, 
and also in their disposition and shape, being in places arranged in 
linear series, and in others in concentric whorls, with definite centres, 



24 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



thus producing crossing-furrows, visible to the naked eye as markings 
upon the outer surface of the epidermis. The largest are found on the 
palms and soles and over the inner faces of the digits. It has been 
estimated that one hundred are developed within each square millimetre 
of the body-surface. 

In horizontal sections of the skin the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas is seen the interpapillary reticulum of the mucous layer. 

The growth of the rete downward and of the corium upward results 
in mutual effects of pressure and counter-pressure the equilibrium of 
which is constantly adjusted by the mechanical and vital necessities 
of such union. 

When the papillae are completely exposed, after removal of the 
overlying cement-substance and of the epidermis above, their exterior 
surface is seen to be uniformly marked with series after series of 
alternating furrows and ridges of exceeding delicacy and more or less 
concentrically disposed. Into the grooves are admitted corresponding 
dentations that can be recognized on the under surface of the layer of 
epithelial cells next the corium. They may, however, be the furrows 
left after separation of the long prickles wrapped about the papillae 
and traceable to the mucous layer. 

Fig. 5. 




Vascular and nervous papillae : a, vessel ; b, nervous papilla ; c, vessel ; d, nerve-fibre ; e, cor- 
pusculum tactus ; /, transversely divided nervous filaments ; g, epithelia of rete. (After Biesia- 
decki.) 



Two varieties of papillae are distinguished — the vascular and the 
nervous ; the former contain the terminal loops of a minute artery and 
vein, and the latter the terminations of medullated nerve-fibres. 



THE EPIDERMIS. 



25 



The greater number of the papillse are of the vascular variety, being 
traversed by a vertically disposed loop of vessels, consisting of an 
arterial and a venous capillary. The office of the vascular loop is 
evidently not merely to supply nutriment for the epidermis above, but 
also to provide for the cooling of the blood when brought in large 
quantities to the surface of the body. Occasionally, two or more of 
such loops can be recognized in a single papilla. 

The nervous papillse contain the tactile corpuscles, which subserve 
an important purpose in providing for the sensibility of the integument. 
The tactile corpuscles are described in connection with the nerves of 
the skin. Ultimate terminations of nerves can be recognized in the 
vascular papillse, and at times minute vascular loops can be seen in the 
papillse largely occupied with the corpuscles of touch. 

THE EPIDERMIS (CUTICULA). 

The epidermis (Scarf-skin, or Cuticle) is the most external of 
the several membranes of the body, being in close contact on one side 
with the corium, or true skin, and exposed on the other to the atmos- 
phere by which it is surrounded. The latter surface is therefore rela- 
tively drier, while the former is constantly moistened by fluids from the 
vessels which ramify beneath it. 

Fig. 6. 




Scalp of a negro— horizontal section: R, rete mucosum; Pi, row of columnar epithelia 
(cut obliquely) supplied with dark-brown pigment-granules; Pa, papilla (cut transversely); 
D, derma. Magnified 500 diameters. (After Heitzmann.) 

No genetic relation exists between the epidermis and the corium, not- 
withstanding their intimate union and mutual relationship. The epi- 
dermis is developed from the ectoderm, the corium from a superficial 
layer of the mesoblast. Their behavior both in health and in disease 
is marked by the widest difference. 

Herxheimer's Spiral Fibres begin with the line of union of the 
corium and epidermis, and run in a spiral or zigzag direction between 
the cells and parallel with their long axes. They are most abundant 
in the deeper portions of the rete, and lie for the most part parallel 



26 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



with the long axes of the palisade rete-cells. They have been supposed 
to be a part of the canal-system for the distribution of the juices sent 
to the rete. They are conspicuous in inflammatory states. Other views 
point to the protoplasmic character of the cell-spirals, as also to the 
possibility that they are related to the collagen of the corium. 

The epidermis varies greatly in thickness in different portions of 
the body ; for example, the epidermis of the palms and soles exceeds 
in vertical section that which covers the dorsum of the hands and feet, 
and that which protects such sensitive parts as the eyelids, lips, 
temples, and prepuce. The epidermis is composed of the following 
principal layers, named in order from within outward : the stratum 
mucosum, the stratum granulosum, the stratum lucidum, and the 
stratum corneum. Each of these strata, or layers, is histogenetically 
derived from the one which is deeper in situation. Beside these, 
Ranvier and others recognize a stratum germinativum, a stratum 
nlamentosum, a stratum intermedium, and a stratum disjunctum. 

The Rete Mucosum (Mucous Layer, Prickle-layer, Stratum 
Mucosum, Rete Malpighii or Malpighianum) is the deepest of 
the epidermal layers, and rests upon the corium below. It is now 
generally designated as " the rete.' 7 The corium is intimately united 
with it by a series of interdigitations, which are commonly described 



Fig, 7. 




Prickle-cells from a condyloma (magnified about 625 diameters) : a, cavity of cell-nucleus ; 
b, nucleus ; c, nucleolus; d, prickles— these are greatly developed on the protoplasm cf the 
cells. The dots on the surface of the protoplasmic mass represent the appearance of the prickles 
when directed toward the eye of the observer. Some of the protoplasmic threads are seen pass- 
ing from one cell to another. 

as prolongations of the derma into the substance of the rete, but it is 
equally true that the rete sends down prolongations (the " rete-pegs ") 
into the derma. The two, in the need of an intimate union to resist 
friction and to insure vascular supply, are thus closely locked together. 
The stratum mucosum is built up of nucleated epithelial cells, poly- 
hedral in outline and diffusely colored. These cells are masses of 



THE EPIDERMIS. 27 

granular protoplasm, living matter, which by their relation to one 
another form a protoplasmic network enveloping the entire surface of 
the body and lining all channels and cavities in direct or indirect con- 
nection with the surface. These elements are flattened by reason of 
their apposition, and are separated from one another by an intercellular 
cement-substance. There is a system of channels between the epi- 
thelia by which the nutritive fluids are conveyed from cell to cell. 
All are, however, uninterruptedly united by delicate spokes, known as 
prickles, spines, or thorns. The living matter, which produces a deli- 
cate reticulum within each protoplasmic body, its points of intersection 
being termed nuclei, nucleoli, and granules, sends forth the filaments 
which produce continuity through all the living layers of the epithelial 
elements, as well as through the underlying layers of the connective 
tissue. The epithelia are unprovided with either blood-vessels or 
lymph- vessels ; but are supplied with a large number of nerves, which, 
in the shape of very minute beaded fibres, traverse the intercellular 
substance, and which are in direct communication with the reticulum 
of living matter within the protoplasmic bodies themselves. 

The masses of protoplasm just described play the most important 
part in all the pathological and physiological processes observed in 
the skin. It is probable that in the embryo all the appendages of 
the skin are formed directly by their assimilative and reproductive 
processes ; and it is certain that in health and in disease they are the 
ultimate source of all secretions. 

Next the corium is a layer {basal layer, stratum germinativum) of 
cells, columnar in form, often largely provided with pigment, and arranged 
with their long axes nearly at right angles to the plane of that portion 
of the corium upon which they are superimposed. The cells of this 
layer are dividing constantly by mitosis, the daughter-cells pushing 
outward to form the succeeding layers. The entire epidermis thus is 
derived from this single (occasionally double) row of columnar cells. 
More externally the cells are rounded or cuboidal in shape, with large, 
distinct nuclei. They are not arranged in definite strata except in the 
outermost layers, where the cells are somewhat flattened and elongated 
(stratum filamentosum). Between the cells in the deeper layers out- 
wandered leucocytes may at times be recognized. 

Langerhans' Cells are elongated, irregularly stellate, non-nucle- 
ated bodies found chiefly in the deeper parts of the rete. They have 
been looked upon as pigment-cells devoid of pigment, as wandering 
cells, lymphoid cells, and as colorless tissue-corpuscles. 

The Stratum Granulosum (Granular Layer) of the epidermis, 
lying immediately above the stratum filamentosum, is built up of three 
or four rows of horizontally disposed granular bodies, united to one 
another by short, broad threads. Between these bodies the intercellular 
spaces are so contracted that nutritive fluids cannot easily filter out- 
ward ; and the nuclei of the cells are usually shrunken. These have 
been studied carefully by Ranvier, Kolliker, Waldeyer, and others. 
According to these observers, the roundish granules which give this 
layer of epithelium its name and peculiar appearance consist of 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

keratohyalin, 1 a substance essential to the process of cornifi cation in 
the elements making up the horny layer of the skin, nails, etc. These 
granules first appear in the neighborhood of the nuclei of some of 
the large prickle-cells in the rete, but they are best studied in the 
granular layer, the cells of which are often completely filled with them. 
According to Unna, the color of the skin in the white races depends 
upon this layer alone. 

The Stratum Intermedium of Ranvier is practically a sub- 
division of the stratum lucidum, from which it is distinguished chiefly 
by the fact that it takes a reddish stain after treatment with picro- 
carmine. It is here that the process of keratinization of the epidermis 
is first to be detected. 

The Stratum Lucidum (Septum Lucidum) of Oehl lies imme- 
diately above the stratum intermedium, and appears under the micro- 
scope as a delicate, brightly colored line consisting of two or three rows 
of transversely disposed, glistening epithelia, differing in translucency 
from those situated on either side. The stratum lucidum thus marks 
with tolerable distinctness the boundary-lines of the rows of cells above 
and below it. Its epithelial bodies seem to have lost suddenly the 
refractive, shining granules of keratohyalin conspicuous in the 
stratum granulosum below. These granules are generally supposed to 
have disappeared in consequence of their solution in the protoplasm 
of the cell-body, which has thus acquired an added brilliancy and 
clearness. 

The Stratum Corneum (Horny Layer) of the epidermis is its 
outermost and widest layer, extending from the stratum lucidum below 
to the external environments of the body. In its lower portion the 
polygonal plates of which it is composed indicate very clearly their 
relationship to the cells in the prickle-layer. The nuclei appear in 
places only as shrivelled and inconspicuous relics of the protoplasmic 
threads ; or there may be merely vacant nuclear spaces marking their 
original site. Occasionally, on the edges, rudiments of the prickle- 
threads may still be recognized. More externally the dried, lifeless, 
horn-like plates of which this layer is composed become mere cornified 
shells, generally lying in horizontal strata, and becoming more curled 
and wrinkled as the surface of the skin is reached, often being imbri- 
cated, but preserving the polygonal outlines of epithelia relieved of the 
forces of pressure and counter-pressure exerted in the deeper parts of 
the epidermis. These elements are rarely pigmented, save in the case 
of the negro, in whom the intense staining of the deepest parts of the 
mucous layer extends measurably to the external strata. This staining 
in the colored races is produced by granules of pigment arranged about 
an unpigmented nucleus in the prickle-cells. The cells of the horny 

1 Keratohyalin is a solid or semisolid substance which is situated in the stratum 
granulosum, and is differentiated well by a hematoxylin stain. It is insoluble in ether, 
alcohol, and chloroform, but is destroyed by strong acids and alkalies. Clinically, it is 
of the nature of hyalin. 

Eleidin is an oily-looking, though not a fatty, substance, situated in the stratum 
lucidum. It differs from keratohyalin physically and chemically, but MacLeod sug- 
gests that it may be a derivative of keratohyalin. Its differentiation requires special 
staining methods. Of. MacLeod's Pathology, p. 61. 






BLOOD-VESSELS. 29 

layer contain fatty material in very considerable proportion, a provision 
by which the suppleness of the skin is maintained and undue evapora- 
tion prevented. Neither keratohyalin nor elei'din is found in this 
layer, but there appears in their place a hard, resistant substance 
termed keratin, to which the hard, dry character of the cells is due. 
Keratin is insoluble in 50 per cent, dilution of mineral acids, and resists 
digestion in a solution of pepsin containing weak hydrochloric acid, 
but is soluble in weak alkaline solutions. 

After digestion with pepsin and trypsin the horny cells may be seen 
to be connected by more or less persistent threads, visible after pro- 
longed digestion as a large-meshed reticulum, with strands formed from 
a double row of cornified filaments united by short horny bridges. 

The Stratum Disjtjnctum of Eanvier is the most superficial of 
the layers of the stratum corneum, differing chiefly from the latter in 
that it is indifferently colored by osmic acid. 

Epitrichial Layer. — Welcker, 1 Minot, 2 and Bowen 3 have de- 
scribed a layer of large cells, with round nuclei much larger than those 
of the epidermal layers beneath, covering the entire body of the human 
embryo during the early months of its existence. This layer, histologic- 
ally, is quite distinct from the outer cells of the stratum corneum, and 
corresponds with the epitrichium of certain animals. It usually dis- 
appears before the sixth or seventh month of uterine life. 

BLOOD-VESSELS. 

The arteries and veins supply the skin from subcutaneous branches 
which penetrate the underlying fasciae, and proceed by subdivision to 
be distributed to all portions of the integument below the epidermis, 
the distribution being especially abundant about the glands and fol- 
licles of the skin and the inferior and superior parts of the corium. 
They are always more abundant upon the flexor than upon the extensor 
faces of the extremities. Just beneath the papillary layer of the 
corium there is a minutely ramifying plexus of fine capillaries, the 
loops of which extend into the papillae above. This and the coarser 
plexus in the deeper portion of the derma are well defined, and have 
been designated as superior and inferior partes vasculares of the corium ; 
also, as the upper and lower vascular net. They are connected by more 
or less regularly placed and nearly vertical communicating branches. 
A fourth division of the vascular system of the skin is found in the 
subcutaneous connective tissue, in which the vessels are numerous ; a 
fifth is represented by the vessels distributed to the papillae; and lastly, 
a sixth includes the vascular channels supplying the accessories of the 
integument. 

The arterioles which supply the sweat-glands surround the coils 
of the latter in a delicate basket-like plexus, and terminate in two or 

1 Ueber die Entwickelung und den Ban der Haut und der Haare bei Bradypus, 
Halle, 1854. 

I Amer. Naturalist, June, 1886. 

3 Anatomischen Anzieger, iv. Jahrgang (1889), Nr. 13 u. 14; and Jour. Cutan. 
Pis., 1895, xiii., p. 485. 



30 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

three veinlets, one of which always accompanies the duct of the gland 
upward as far as the papillary layer, where it anastomoses with the 
vessels of that part of the skin. The ascending arterioles supply the 
sebaceous glands and hair-follicles, and, breaking up into smaller and 
yet smaller branches, finally furnish a single or a double capillary loop 
to each papilla. These capillaries of the papillary layer anastomose 
freely with those transversely arranged in the upper portion of the 
hair-follicles, from which loops also pass to the sebaceous glands. The 
hair-papilla has a vascular supply similar to that of each of the other 
papillae of the corium. 

Unna divides the vessels distributed to the skin into the papillary 
system and the system of the coil-glands and fat-tissue. The first 
system includes the ascending loops which traverse the vascular pa- 
pillae, and the branches supplying lower portions of the corium. The 
second system embraces the vessels running upward to the coil-glands 
and downward to the fat-tissue. In the papillary vascular system the 
arteries are narrow and the veins wide. Each of the vessels consists 
merely of an endothelial tube augmented, as the subcutaneous tissue is 
reached, by both media and adventitia. According to Hoyer, a sin- 
gular duplex arrangement of vessels in the distal phalanges of both 
fingers and toes results in a distinct communication between the arte- 
ries and veins. Other observers deny the existence of such anas- 
tomosis. 

Vasomotor nerves are twined around these vessels in all their rami- 
fications. The whole vascular system, as thus arranged, plays a most 
important part in all the healthy and morbid processes which occur in 
the skin, as well as in the physiological changes distinguishable to the 
eye in the phenomena of blanching and blushing. 

LYMPHATIC VESSELS. 

The skin in all its parts is provided with a closed system of lym- 
phatic channels, designed to subserve the necessities of the important 
processes of absorption, and traversed by lymph the currents of which 
are continuously directed to the large vessels of the structures beneath 
the skin. These channels include : first, juice-spaces, provided or not 
with independent walls, usually without, and not freely communicating 
with the endothelium-lined vessels ; second, lymphatic vessels proper. 
These conduits do not connect with blood-vessels. 

The juice-spaces, or lymph-spaces, separate the epithelial bodies which 
make up the stratum mucosum of the epidermis, and they also extend 
between the protoplasmic threads, or prickles, that unite them. Such 
conduits may be regarded either as delicate excavations in the cement- 
substance between the epithelia, or as irregular channels in a soft, 
viscid, albuminoid, and readily coagulable substance between the pro- 
toplasmic threads. At times this intercellular substance seems capable 
of obstructing the conduits by which it is tunnelled. These juice- 
spaces exist in the papillae of the corium, and encircle the several 
glands, hair-follicles, and nail-beds of the skin. They also sheathe 
the connective-tissue fibrillar of the corium and surround the fat-cells. 
According to Darier, the derma is a " true lymphatic sponge." 



NERVES. 31 

The lymphatic vessels are relatively few, but they form a continuous 
meshwork with transversely and vertically disposed branches supply- 
ing all parts of the skin below the epidermis. The juice-spaces com- 
municate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As these vessels pass 
to the deeper portions of the corium and below it they increase in size. 
The current of the lymph flows from the papillary apices to all parts 
of the rete, like the currents in the delta of a river, a reflux occurring 
at the lower limit of the interpapillary depressions of the rete down- 
ward, possibly through the sweat-pores which traverse the epidermis 
at these points. Thence the current flows freely downward to the 
lymphatic vessels in the corium, but the stream from the juice-spaces 
about the coil-glands and fat-tissue is retarded by reason of a more 
restricted communication with the lymphatic vessels below. In conse- 
quence of the retardation due to this anatomical peculiarity the forma- 
tion of fat by filtration is facilitated. 

NERVES. 

The skin, in view of the number and mode of distribution of its 
nervous elements, may be regarded as a vast area of sensitive nerve- 
terminals. Non-medullated and medullated nerve-fibres, each in places 
being substituted for the other, are supplied to the skin from horizon- 
tally disposed bundles of nerve-twigs in the subcutaneous tissue. These 
fibres traverse the corium in connection with the blood-vessels, and 
become finer as they ascend, until they form a subepithelial plexus just 
below the epidermis. 

Exceedingly delicate Non -medullated Fibres penetrate in great 
abundance to the epidermis between the epithelia, and are not to be 
confounded with the migratory cells found in this situation. Here, 
traversing the intercellular substance by the side of the juice-spaces, 
these fibres either terminate between the prickle-cells as ultimate bul- 
bous terminations of finely beaded fibrillar, or penetrate the epithelia them- 
selves in pairs. Each prickle-cell is supplied with a pair of these beaded 
filaments, which may be either applied to the nucleus of the cell or be 
seen to encircle the nucleus more or less completely. Above the stra- 
tum granulosum these nervous threads cannot be recognized. 

Similar nerve-filaments are supplied to the sheaths of the hairs and 
the ducts of the coil-glands. It is by means of these numerous and 
delicate fibres that the perception of sensation in the skin is accom- 
plished. 

Motor filaments are also distributed to the sheaths of the blood- 
vessels (vasomotor nerves), in which they are finally lost. Other motor 
filaments supply the muscles, and trophic nerves are distributed to all 
the secreting organs of the skin and to all its protoplasmic formations. 

The Medullated Nerve-fibres of the skin in one or several loops 
pass upward into the papillae, and then turn backward to the subpapil- 
lary region. Some of these fibres, after such reversion, again ascend to 



32 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



an adjacent papilla ; others are supplied to the Pacinian and tactile cor- 
puscles. 



Fig. 8. 





n.g.p 



Pacinian body, after silver staining, 
showing superimposed endothelial lay- 
ers. (After Renaut.) 



Section of Pacinian body from a duck's bill; 
g.L, lamellar envelope; g.h, hyaline zone of the 
lamellar envelope ; b.t, terminal bulb of the nerve ; 
g.p, n.g.p, layer investing the cavity of the body. 
(After Renaut.) 



The Pacinian Corpuscles (named from the anatomist Pacini), also 
called Corpuscles of Vater, exist subcutaneously only upon nerves 
intended for cutaneous supply ; they are ovoid bodies, two or more mil- 
limetres in diameter. Each corpuscle consists of a series of concentric, 
nucleated, vascular capsules, arranged after the manner of the capsules 
of the onion, more closely united at the periphery than at the centre, 
and surrounding a protoplasmic core. The medullated nerve to which 
the body is attached gradually loses its myeline envelope, and termi- 
nates in the centre of this core, after traversing the greater part of its 
axis, in one or several minutely club-shaped filaments. The myeline 
sheath is lost in the tissue of the concentric capsules. The nerve may, 
after supplying one capsule, penetrate a second or even a third. In 
such cases the nerve regains its sheath as it issues from the corpuscle at 
its opposite pole. Pobinson believes that the nerve forms a plexus or 
loop within the corpuscle, and escapes from it at one of its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since 
these bodies are most numerous in the subcutaneous tissue of the nipple, 
the penis, the digits, and in parts similarly sensitive. These corpuscles 
bear an analogy to the organ of vision : each body having a capsular 
character ; each being provided with a special nerve-filament, which 
enters the corpuscle at one pole ; each also receiving its impressions at 
the extremity of the capsule opposite that at which it receives its 
nervous supply. 



NERVES. 



33 



According to Krause, the Pacinian corpuscles aid in the appreciation 
of impressions produced by pressure and traction. Whether specially 
concerned in distinguishing sensations of heat, cold, moisture, pressure, 
traction, or weight, it is evident that they contribute but little, if at all, 
to the perception of ordinary impressions upon the skin, and they are 
not known to play any part in cutaneous diseases. 



Fig. 9. 




Section of a papilla still covered by a portion of the stratum mucosum and containing a 
tactile body (from the skin of a finger). The corpuscle of Meissner is seen to consist of minute 
lobules, made up of a homogeneous protoplasm, with numerous oval nuclei and nervous fibrillae 
wound in a spiral direction about the mass of the corpuscle. The extension of the fibrillar to the 
mucous layer is shown. The sources of the nerve-filaments are demonstrated to be : (1) the axis- 
cylinders of one or two double-contoured nerve-fibres, splitting into their original fibrillae on 
arriving at the corpuscle, winding about the latter in characteristic spirajs, and passing to the 
palisade-layer of the prickle-cells of the rete. between which, on account of the long prickles 
of the latter and the general resemblance of the two in thickness and contour, it is difficult to 
trace them further; (2) filaments from another double-contoured nerve-fibre (h) pass directly to 
the inferior layer of cells in the rete without establishing relations with the tactile body; (3) 
fibrillc2 derived from the network of nervous fibrillee in the pars papillaris of the corium (K), 
also passing more or less directly to the stratum mucosum. a, cells of the rete ; b, prickles of 
the latter; c, body of papilla ; d, nuclei of connective tissue forming papilla ; e, protoplasmic part 
of the tactile body with its nuclei; /, fibrillar of the corpuscle; g, double-contoured nerve-fibres 
directly supplying the rete ; k, nervous fibrillae derived from the network in the pars papillaris ; 
I, nervous fibrillar entering the epidermis between the rete-cells, leaving the cornusculum tactus 
at m 

The Tactile Corpuscles (Corpuscles of Meissner or of Wagner) 
are ovoid bodies found in about one in four of the papillae in the pars 
papillaris of the corium. Each corpuscle is composed of from one to 
three capsules. Minute lobules of a homogeneous protoplasm with 
oval nuclei are found in each. These corpuscles receive medullated 
nerve-fibres, and are made up of closely compressed, flat connective- 

3 



34 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



tissue fibres with minute nuclei, which are so packed together as to 
form a spindle-shaped mass occupying the greater part of the papilla 
in which each corpuscle is found and surrounded by a somewhat denser 
connective-tissue capsule. The myeline sheath of the nerve-fibres is 
lost in the fibrous tissue of the corpuscle. Externally viewed they 
seem to be transversely striated. 

The axis-cylinder of the nerve-filament distributed to each corpuscle 
divides into numerous delicate nerve-threads which in part encircle the 

Fig. 10. 




Transverse section of nervous papilla surrounded by cells of the stratum mucosum : a, 
protoplasmic lobules of the corpusculum tactus; b, nervous fibrillae spirally wound about the 
latter; c, transverse section of double-contoured nerve-fibres; d, cavity of nucleus (out of focus). 

corpuscles and also penetrate within. Each corpuscle is provided with 
an afferent and an efferent nerve, the former approaching the corpuscle 
from the subpapillary region and entering at or near its base. Occa- 
sionally the afferent fibre is furnished by an adjacent papilla. As the 
filament that enters the corpuscle frequently divides, two or more 
efferent fibres may then escape from it. Afferent fibres reach the rete 
above after encircling the tactile corpuscles ; others, side by side, arrive 
at the rete without coming into contact with the former. 

The discovery of nerve-filaments in and among the epithelia of the 
epidermis in such abundance as to provide fully for tactile sensation 
in the skin leaves the exact function of these corpuscles in partial ob- 
scurity. There can be little doubt, however, as to their association 
with the perception of certain qualities of foreign bodies with which 
the skin may be brought into contact. 

Merkel's Touch-cells are oval, nucleated bodies found in the 
lower animals, but also in man. They are supposed to be connected 
with the ultimate nerve-fibres. They resemble cells in a mitotic state, 
and are found in the upper part of the corium as well as the epidermis, 
and in regions in which the tactile corpuscles are few, as over the 
abdominal surface. 



PIGMENT. 35 

The Corpuscles of Krause (Bulb-corpuscles : Kolbejs t kor- 
perchex) are rounded or oval-shaped bodies formed of a connective- 
tissue envelope and a non-nucleated bulb to which some delicate nerve- 
fibres penetrate. These bodies are found chiefly along the borders of 
the lips, over the glans penis, the clitoris, and the tongue. 

PIGMENT. 

The hue of the living integument is due in part to the degree of 
vascularity and distention of the vessels in the corium, and in part 
also to pigmentation of the epidermis. The coloring-matter of the 
skin in health is deposited chiefly in from one to four rows of cells 
in the lower stratum of the rete, the fine granules of pigment staining 
both the cell-body and the nucleus, the latter more vividly. The 
degree of vascularity of the skin is responsible for most of the flesh- 
tints, but the colors seen in the various races of men are wholly related 
to the character and quantity of pigment found in the rete. Rarely, 
pigment-cells are found in the corium in a state of health. This 
pigmentation depends upon a distinct and uniform coloration of the 
epithelia, and also upon minute granules of pigment entangled in the 
reticulum of living matter in the same part. Extreme variation in 
the distribution of pigment is noticeable both in health and in disease, 
and in individuals and races, being at times related to climatic and 
similar influences. This fact is well illustrated by the wide range 
between the flaxen-haired, pink-eyed albino and the blackest specimens 
of the negro, each, with small exception, being of African descent. 

It has already been noted that in the colored races the pigment may 
stain the epithelial cells and their nuclei as high as the granular layer ; 
and that to this layer only is due the characteristic color of the skin 
of the white races. Pigment is not normally found either in the horny 
layer of the skin or in the subepithelial tissues. Waldeyer claims to 
have recognized it in normal connective tissue. 

The source of the pigment in the skin has not been positively de- 
termined. It is believed by some to be carried by leucocytes from the 
corium beneath to the rete above ; others have thought that the pig- 
mented cells themselves were capable of migration. Yet others teach 
that the pigment is produced de novo within the rete-cells. It is most 
probable that the pigment is derived from the subepidermal structures, 
and is originally obtained from the blood itself. 

The relation existing between the two sources of skin-coloration, 
viz., the blood and pigment, is interesting and suggestive. The un- 
aided eye, looking at the outer surface of the body, makes little dis- 
tinction between these two color-sources. It is certain that solar heat 
exerts a manifest influence upon both, and that in extravasations of 
blood into the substance of the skin every shade of color visible in the 
spectrum may at times be distinguished. 



36 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

MUSCLES. 

Striated Muscular Fibres extend from the subcutaneous tissue into 
the derma ; in the case of man they are found chiefly upon the face 
and neck, where they are the analogues of more powerful skin-moving 
muscles possessed by several of the lower animals. Some, as those in 
the region of the face, serve to give expression to mental emotion by 
the production of facial movements. 

Non-striated Muscular Fibres exist either as minute oblique fas- 
ciculi in connection with the glands and follicles of the skin ; or as 
annular bands, .such as those which surround the nipple ; or as radiat- 
ing and more or less parallel rods, such as antagonize the orbicularis 
in the eyelids. 

The Arrectores (Erectores) Pilorum are muscles found usually 
in connection with the hair-follicles. They originate by minute multiple 
fasciculi from the papillary portion of the corium, and are inserted at 
several points into the outer layer of several adjacent hair-follicles, just 
above the plane of the apex of the hair-papilla. Their general direc- 
tion is oblique, and their muscle-bundles are embraced and traversed 
by elastic fibres which form a dense network about them. Elastic 
threads also connect them intimately with the connective-tissue bun- 
dles of the corium, and serve as tendons at either extremity of each 
muscular fasciculus. 

The muscles, by virtue of their oblique direction and mode of attach- 
ment, include in the angle subtended by their muscular fibres the 
sebaceous glands connected with the hair-follicles. It follows, there- 
fore, that by their contraction they aid in the expulsion of the seba- 
ceous secretion formed in the gland ; but their intimate union with 
the elastic tissue, which is evenly and generally distributed throughout 
the framework of the corium, results in their discharge of a still more 
important function in connection with the regulation of the body-tem- 
perature, since by virtue of direct compression exerted upon the skin 
the blood may be driven from the surface in a centripetal direction 
and its cooling in a great degree prevented, as in the well-known 
phenomena resulting in the production of the cutis anserina, or " goose- 
flesh." The reverse of this naturally follows when the muscles expand 
under the influence of external heat. The anatomical connections of 
the arrectores pilorum are such that their contraction serves to ap- 
proximate several of the papillae of the corium, including the hair- 
papilla. Thus, by their contraction the sebaceous secretion may be 
extruded, or, as is more particularly exhibited in the lower animals, 
such hairs as the bristles of the boar may be erected. 

Muscular Membranes exist in the skin of the scrotum, over the 
penis, about the nipple, and elsewhere. They are simply layers of 
smooth muscular fibres, which suffice when contracting to move the 
portions of skin to which they are distributed. 






HAIRS. 37 



HAIRS. 



Hairs are cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions in 
the rete and corium, known as " hair-sacs," or " hair-follicles." They 
are found on all the superficies of the body except the palms and 
soles, the dorsum of the distal phalanges of the hands and feet, and 
the skin of the penis. Hairs occur in three tolerably distinct classes. 
These are : the fine, downy hairs, or lanugo, covering the face, the 
trunk, and the limbs ; the long, soft hairs, such as those implanted 
upon the scalp, the pubes, and the axillse ; and the short hairs, includ- 
ing the soft varieties seen upon the brow and the stiff hairs of the 
eyelids. 

The hairs are first developed in the third month of foetal life, when 
a short epithelial cone is formed, the base of which is gradually sur- 
rounded by connective-tissue cells, and finally indented from below by a 
rudimentary hair-papilla. Gradually the tip of the rudimentary hair 
perforates the primitive hair-cone and becomes a mature filament. 
At' about the period of birth, sometimes earlier, occasionally later, 
the "bed-hairs/' as they are called by Unna, are replaced by papil- 
lary hairs. The term bed-hair is applied to primary hairs unprovided 
with papillse, and implanted in shallow follicles, from the sides of 
which productive epithelial offshoots have been sent out. Usually at 
the end of foetal life these bed-hairs have been for two months growing 
out of the hair-bed, or that part of the epithelium found in the cen- 
tral part of the hair-sac. 

Hairs thus differ from nails not only in their anatomical features, but 
particularly as to their physiological reproduction. Hairs are period- 
ically cast off and replaced by new filaments. The nails are shed and 
reformed only in disease ; in health they enjoy a continuous growth 
during the life of the body. When a hair is about to be shed it sepa- 
rates from its papilla in the hair-follicle and rises in the latter till it 
reaches above the level of the papillary apex. It is for a time held 
in place with sufficient firmness by the prickle-layer only, thus forming 
the bed-hair already described. Later an epithelial bud is projected 
either into the vacant follicle below or into the corium on either side, 
from which a new hair is formed, somewhat as the hair is formed in 
the primitive cone of foetal life. The subsequent growth outward of 
the new papillary hair separates the bed-hair from its connection with 
the prickle-layer, and this filament is shed. 1 

In studying the mature hairs the parts to be considered are the 
hair-follicle, and the bulb, shaft, and point of the hair. 

Hair-follicle. — The hair-follicle is a sac-like pouch in the corium, 
in which depression the hair-filament is implanted by its bulb and there 
firmly secured. The direction of this follicle is always at an oblique 
angle with the plane of the cutaneous surface upon which it opens, and 
thus is determined the set of the hairs, which is always fixed and at a 
similar angle. " Viewed as a whole, the integument of the body over its 

1 Cf. Veneziani, Giorn. ital., 1901, xxxvi., p. 582 (abstr. in Brit. Jour. Derm., 1902, 
xiv., p. 325. 



38 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



entire area exhibits determinate whorls of both short and long hairs 
with definite centres, such as those which may be recognized at the 
vertex of the scalp, the centres of the lips, the umbilicus, etc. By this 



Fig. 11. 



Fig. 12. 





Section of a hair-follicle during the forma- 
tion of a new hair : a, external and middle 
root-sheaths ; 6, vitreous membrane ; c, papilla 
with vascular loop ; d, external root-sheath ; 
e, internal root-sheath ; /, cuticle of hair-fol- 
licle ; g, cuticle of hair ; h, i, young hair ; I, 
bulb of old hair; k, debris of external root- 
sheath of hair recently expelled. (After 
Ebner.) 



Hair-follicle in longitudinal section : a, 
mouth of follicle ; b, neck ; c, bulb ; d, e, der- 
mic coat ; /, outer root-sheath ; g, inner root- 
sheath ; h, hair: k, its medulla; I, hair-knob ; 
in, adipose tissue ; n, hair-muscle ; o, papilla 
of skin ; p, papilla of hair ; s, rete mucosum, 
continuous with outer root-sheath ; ep, horny 
layer ; t, sebaceous gland. 



disposition the symmetrical appearance of the hairy parts is preserved, 
and, as a consequence of the same provision, physiological loss of the 
hair of the head is not productive of deformity, but rather adds dignity 
to the aspect of the elderly man. 



BA1BS. 39 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is imbedded in the skin, together with the envelopes of 
the latter, termed the hair-sheaths. Above the sebaceous glands the 
sheaths of the hair-follicle are lost in the papillary layer. The follicle 
is constituted of the connective tissue of the corium in three layers : an 
external longitudinal fibrous layer ; a middle transverse layer ; and 
an internal homogeneous or vitreous layer. At the base of the sac a 
fibrous pedicle may often be traced as low as the subcutaneous tissue. 

If the hair-pouch were made artificially by thrusting into the skin 
from without inward a blunt-pointed pin before which the tissue was 
gradually pushed, it is evident that the external layer, the stratum 
corneum, of the epidermis would be the first depressed, and finally 
would form the inner surface of the pouch. This represents the inner 
root-sheath of the hair. Xext to this the pin would carry before it the 
mucous layer of the epidermis, which then would form the outer root- 
sheath of the hair. Outside of both would lie the connective tissue of 
the corium. 

The Outer Root-sheath, or the prickle-layer of the hair-follicle, 
accompanies the involutions of the stratum corneum and the stratum 
granulosum from without into the funnel-shaped neck of the hair-pouch 
as far as the openings of the ducts of the sebaceous glands. There, 
abandoned by the two other layers of the epidermis, the root-sheath is 
thinned in proportion as the papilla, which rises from below and which 
it closely surrounds, increases in size. It thus forms a hollow cylinder 
traversed by the hair and its envelopes, with a relatively wide, external, 
funnel-shaped opening, only partially filled by the shaft of the hair, 
and a narrower opening within, which embraces the neck of the hair- 
papilla. 

The Inner Root- sheath, or " matrix " of the root-sheath, is exter- 
nally in relation with the outer root-sheath, or prickle-layer, of the hair- 
follicle. The protoplasm of the cells of which it is constituted contains 
keratohyalin in varying quantities, the amount being naturally greater 
in the cells lying nearest the hair-filament. That part of the sheath 
formerly termed " Henle's layer " is the more externally situated cel- 
lular envelope of this internal root-sheath, and is most conspicuous in 
that part of the hair-sac above the level of the papilla. That part of 
the sheath formerly called " Huxley's layer " is the more internally sit- 
uated part of the same sheath, somewhat higher in the follicle. These 
are not distinctly different structures, but only a single structure in 
different situations. Whether termed the internal root-sheath or the 
matrix of the root-sheath, it springs from the neck of the papilla, and 
rises as high as the neck of the follicle. It contains keratohyalin, which 
is actively concerned in the cornification of the hair-tissue. 

Between this internal root-sheath and the cells constituting the cor- 
tex of the hair there is found, according to Unna, the common matrix 
of the cuticulse, forming respectively the cuticle of the root-sheath and 
the cuticle of the hair. The former is composed of cells with their 
long axes parallel with the circumference of the hair, while those 
forming the cuticle of the hair are arranged perpendicularly to the sur- 



40 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



face. These cuticulse are locked securely together by projection of 
their cell-edges, while united in the hair-follicle. 

The Bulb (or Boot) is that portion of the hair imbedded in the 



Fig. 13. 




Lower portion of hair-pouch from the lip of a kitten: F, follicle; T, transverse section of 
connective-tissue bundles of derma ; M, arrector pili muscle ; IS, inner root-sheath : OS, outer 
root-sheath; P, papilla ; C, cuticle; R, root of hair ; H, hyaline, or so-called "structureless," 
membrane. Magnified 500 diameters. (After Heitzmann.) 

skin, toward which the shaft of the hair gradually increases in thick- 
ness as it descends. The bulb is embraced by the hair-follicle, though 
its root-sheaths are interposed and implanted below at the base of the 
sac upon a nipple-shaped prolongation of the corium that may be re- 
garded as analogous to the vascular papillae of the papillary layer of 
the corium. 

The bulb of the hair embraces the papilla, and is constituted of pig- 
mented cells externally, forming what is called the " cortex " or cor- 
tical portion. This is the larger of the two structures of which the 
hair is composed, and its cells become vertically elongated and narrow 
as they are pushed outward in the process of growth. 




HAIRS. 41 

The Shaft of the Hair is that portion which extends from the exit 
of the hair at the surface of the skin to its extremity ; the latter, when 
uncut, always tapers to a perfectly acuminate point, as illustrated by 
the uncut hairs of the eyelids and those of 
the lower animals. The hair-shaft is either Fig. 14. 

straight, curled, wavy, or alternately varied 
in diameter. A transverse section pre- 
senting an ovoid or ellipsoidal outline sug- 
gests an irregularly compressed circle. The 
degree of this flattening varies in different 
races, and is the cause of variability with 
respect to straightness or curliness. As 
hairs are to a marked degree hygroscopic, 
and not only absorb but can be deprived 
of a portion of their water, these states of 
waviness are subject to variation according 
to the aqueous condition of the media by 
which an individual is surrounded. 

The color of the hair is dependent upon 
the pigment it contains, the color of the Tran ^rse section of hair and 
hair-cells, and the quantity of air contained 

in the medulla. Variation in these three factors produces the wide 
range between a snowy whiteness and an ebony black. 

The coloring-matter of the hair is thus stored in both its horny and 
its medullary portions, and is distinct both within and between the 
epithelial elements of which the hair is composed. This pigmentation 
corresponds in great part with the amount of pigment distributed to 
other parts of the integument, and sustains a close relation to the 
general nutrition of the body. Its subjection to the influence of the 
trophic nerves is well demonstrated by the phenomena of rapid blanch- 
ing of the hairs. Excessive sweating, whether physiological or induced 
by the action of pilocarpine, has also a distinct influence upon the shade 
of color of hair. 

The membrane which invests the shaft of the hair is the cuticle, 
composed of numerous flattened plates, non-nucleated and non-pig- 
mented, regularly overlaid so as to resemble closely adherent fish-scales 
when viewed under the microscope on the flat side, and the overlapping 
tiles of the roof of a house when seen on the edge. 

The Cortex of the hair, constituting the greater part of its bulk, is 
composed of flat, nucleated, pigmented, fusiform epidermal cells. The 
strength, elasticity, and extensibility of the hair are chiefly due to the 
cortical substance, and in particular to the firmness with which these 
epidermal cells are attached to one another. 

The Medulla of the hair is found best developed in the short, strong 
hairs of the beard and eyelashes, being wanting in the lanugo-hairs. 
It consists of a loosely packed mass of epidermal elements with inter- 
spersed air-spaces, differing in shape, developed in the centre of the 
axis of the shaft. This part of the hair contains also the pigment and 
fatty matters, which are here arranged as in the rete of the epidermis. 
Seen under the microscope, the medulla appears as a continuous or 



42 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

interrupted longitudinal band extending from the bulb, or the part 
implanted in the follicle, to the extremity, or point, of the hair. The 
purpose of this difference in the constitution of the cortex and medulla 
of the hair is doubtless to insure, on well-known mechanical principles, 
a maximum of strength, extensibility, and elasticity, with a minimum 
of volume. 1 

SEBACEOUS GLANDS. 

The sebaceous, or sebiparous, glands are pyriform bodies, usually 
racemose in development, situated in the corium, never in the subcuta- 
neous tissue ; they furnish a more or less consistent and fatty secretion 
destined to anoint the skin and hairs. They can usually be distin- 
guished as of three classes, though only two of these classes include 
glands which are associated with hairs in the embryo. 

The first class includes the sebaceous glands, which, strictly speak- 
ing, are appendages of the hairs and hair-follicles. They are developed 
early in foetal life from minute, lateral, bud-like prolongations from 
the outer root-sheath of the hair. From two to six of these prolonga- 
tions spring from the prickle-layer of the hair-follicle, and the prickle- 
cells in the axis of each bud speedily undergo fatty metamorphosis. 
In the mature gland each acinus is formed of a membrana propria 
supporting layers of nucleated cuboidal epithelia undergoing fatty 
metamorphosis. Gradually the fatty cells are pushed outward toward 
the duct of the gland, where, sooner or later, their rupture releases 
numerous drops of fat (sebum) just where the hair emerges from the 
closely applied follicle below to the funnel-shaped mouth of the hair- 
pouch above. Externally each gland is provided with a layer of con- 
nective tissue. Sebaceous follicles are found in connection with the 
long, soft hairs, as those of the scalp and the axillae, several being 
grouped around a single hair-sac. 

The second class includes the large and complex glandular structures 
to which the lanugo-, or rudimentary, hairs seem accessory, the orifices 
of their respective ducts opening directly upon the cutaneous surface. 
These glands are chiefly found upon the glabrous portions of the skin, 
as upon the face in both sexes and upon portions of the trunk and 
extremities. 

The third class includes those sebaceous glands, much the smallest 
in number, opening directly upon the surface and unconnected with 
hairs or hair-follicles. Such are the glandulae odoriferae of the male 
and female genitalia, and those existing abont the lips and in the areola 

] Pinkus (Zeitschrift, 1902, ix., p. 465; Ibid., 1903, x., p. 225) describes peculiar, 
glistening disks, from 0.25 to 0.5 mm. in diameter, situated adjacent to the lanugo-hairs, 
and lying in the acute angle formed by the hair with the skin. They are most easily 
seen, by the aid of strong reflected light, on the flexor surface of the forearm or 
upper arm, but occur on other parts of the body. They are most numerous in males 
from eighteen to thirty years of age. Microscopically the structure differs slightly 
from that of normal epithelium, and by special staining shows a rich supply of nerve- 
fibrils derived from the nerve of the hair-follicle. These disks have been found in the 
skin of man only, but resemble closely the touch-plates found in crocodiles and in a 
peculiar lizard found in Australia. Pinkus believes that these hair-disks play a part in 
the sensory functions of the skin. 



SEBACEOUS GLANDS. 



43 



of the nipple. These glands might be designated as "glands of the 
mucous orifices.'' 1 

The Meibomian and Tysonian Glands are of the largest order 
of sebaceous glands. The former exist within the free border of the eye- 
lids ; the latter, upon the glans penis and the inner face of the prepuce. 
They are unconnected with hairs, and in this respect differ from other 
types of sebaceous glands. 

Fig. 15. 




Sebaceous glands of the second class, from the alae of the nose. (After Sappey.) 

The Glandule Ceruminosjs are situated in the sebaceous tissue 
of the meatus of the ear, and contribute to the waxy secretions there 
furnished. The "glands of Moll" found in the eyelids are to be 
classed with the sweat-glands. 

The Sebaceous Secretion contains, chemically, water, palmitic and 
oleic acids, palmitin and olein soaps, and the saline constituents of the 
other organic animal compounds, chlorides and phosphates of the alka- 
lies and earths. The extrusion of the secreted sebum from the ducts 
of these glands is greatly favored by the action of the arrectores pilo- 

1 An unusual development of the sebaceous glands is seen occasionally on the 
raucous membrane of the lips and cheeks. They have a milium-like, but yellowish, 
appearance, and may be few in number or so closely set as to form a yellowish patch. 
The condition was described first by Fordyce (Jour. Cutan. Dis., 1896, xiv., p. 413), 
and later by D. W. Montgomery, Hay, and others. For bibliography, see Stelwagon, 
Diseases of the Skin, p. 1092. 



44 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



rum muscles, by the contractions of which the gland is to a degree com- 
pressed. This* is the reverse of what occurs in the coil-glands, the 
secretion of which is impeded by the action of these same muscles. 



COIL-GLANDS. 

The coil-glands (Sweat or Sudoriparous Glands, Glandule 
Glomiformes), found within the skin of all regions of the body, are 
globular coils situated in the subcutaneous tissue and in the deeper 
portions of the corium. They appear first in the fifth month of foetal 

life as buds projected down- 
ward from the prickle- 
layer of the epidermis. 
These projections always 
form between the papillae 
of the corium, and spring 
from the rete-pegs between 
these papillae. Long, thin 
cones of epithelium thus 
gradually traverse the co- 
rium, and become slightly 
bulbous at the lower ex- 
tremity to form later the 
coil. The lumen, when 
formed, extends rapidly to 
the epidermis, and after 
this is reached there is 
formed from within out- 
ward an opening, which 
becomes the sweat-pore. 

After birth these glands 
are found in all parts of 
the body, but in certain 
regions, such as the axillae, 
the groins, the palms, the soles, and about the anus, the coil-glands are 
multiple, of unusual size, and often peculiarly arranged. They are 
specially numerous in the palms and soles, where, according to Krause, 
there are between two and three thousand to the square inch. 

The Coil is a convoluted tube, of fairly uniform lumen, terminating 
in a csecal pouch, lined with nucleated cubical epithelia in a single 
layer of granular appearance, which are the secretory cells of the gland. 
Outside of the tube are smooth muscular fibres running parallel with 
or in a spiral direction about the coil. Surrounding both muscle- 
bundles and epithelium is a connective-tissue membrane. The glomer- 
ulus, or coil, is globular in outline and reddish yellow in color. In 
the larger glands irregular dilatations and constrictions of the tube are 
conspicuous. 

The Excretory Duct of the coil-gland passes from the glomerulus 
below to the epidermis above in a straight or a spiral course. It is 
lined with a delicate hyaline cuticle (discovered by Heynolcl), beneath 
which is a double layer of cuboidal epithelium. Externally is a mem- 




Coil of a sweat-gland: S, tubule lined with cuboidal 
epithelia ; T, central calibre of the tubule ; D, beginning 
of the duct; C, connective tissue with injected blood- 
vessels. Magnified 500 diameters. (After Heitzmann.) 



COIL-GLANDS. 



45 



brana propria, unprovided with muscular fibres. Its outermost sheath 
is the usual connective-tissue layer. When the duct reaches the border- 
line of the epidermis, its inner cuticle and external connective-tissue 
sheath both are lost ; here it becomes a sweat-pore. It opens at times 
within a hair-pouch. 

The Sweat-pore is a continuation of the excretory duct of the 
coil-gland after the loss of its cuticle and connective-tissue sheath. It 
is the loss of these sheaths and the consequent intimate relation of the 
canal to the epithelia of the epidermis that furnish the special basis 
for this distinction. The sweat-pore is merely a wall-less canal or chan- 
nel, spirally directed or running a straight course from the duct of the 
coil-gland below to the outermost stratum of the epidermis above. It 

Fig. 18. 




Sweat-pore traversing the epithelial layers of the skin : BP, papilla with injected blood- 
vessels ; V, valley between two papillae; Z\'duct in the retemucosnm; E, E, epidermal _ layer ; 
PL, coarsely granular epithelia, deeply stained Avith carmine ; P, duct with corkscrew-windings 
in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

has no other wall than that formed by the cells of the prickle-layer 
below and of the other layers of the epidermis, which successively sur- 
round this canal, narrow below and funnel-shaped above. Elei'din- 
granules are found in the cells which border the sweat-pore at a some- 
what lower plane than the stratum granulosum. Hence the lumen of 
the sweat-pore, if such a term be permissible, is in free communication 
with the juice-spaces of the epidermis. 

The Secretion of the coil-glands consists largely of globules of fat 
and granules of pigment. The function of the coil-glands, therefore, 
is plainly the lubrication of the skin with unguent, a task performed 
only in small part by the sebaceous glands, and by them chiefly for the 
pilary covering of the body. The palms of the hands and the soles of 
the feet are thus lubricated with fat by the coil-glands. 

The total number of coil-glands in the body is estimated to be 
between two and three millions, and the total length of the uncoiled 
glands about eight miles. These figures serve to give an approximate 
idea of their great physiological importance, and of the extent to which 



46 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



violation of the rules of hygiene possesses interest from a pathological 
point of view. 

Fig. 19. 




Section of the skin from the palm of the hand (hardened in Moeller's fluid and treated with 
glacial acetic acid), magnified 300 diameters, showing epidermis and pars papillaris of the corium 
traversed by the excretory duct of a coil-gland terminating in a sweat-pore : a, stratum corneum : 
a', its superficial layer, the cells in the upper and lower layers somewhat larger than those 
situated between the two ; b, stratum lucidum ; c, stratum granulosum ; d, stratum mucosum ; 
e, rete-pegs ; /, interpapiilary process of rete meeting duct of coil-gland: g, g, papillae em- 
braced by long prickles extending from lower palisade-layer of the rete ; h,' blood-vessels of 
papillae; i, bundles of connective-tissue fibres of pars papillaris; k, section of spiral duct of 
coil-gland and sweat-pore. 

The function of the sweat-pores which communicate directly with 
the excretory ducts of the coil-glands is distinct from that of the coil- 
glands, since it provides for the transmission outward of the watery 



COIL-GLANDS. 47 

fluids of the skin. The channel described as the sweat-pore is an ample 
and free communication with the intercellular spaces of the epidermis ; 
and this anatomical peculiarity provides fully for the needs of evapo- 
ration at the surface of the body. 

The Sweat excreted by the body differs under varying conditions of 
temperature, humidity of the air, and the amount and character of the 
articles ingested by the individual, either as food, drink, or medica- 
ment. Nearly 98 per cent, of the secretion is pure water, the remain- 
ing proportions representing the saline constituents of the other fluids 
furnished by the animal in life. In all chemical analyses of the sweat 
a source of error lies in the difficulty of securing the fluid secretion 
unmingled with that produced by the sebaceous glands ; and the same, 
it may be said in passing, is true of the chemical analysis of the sebum. 
According to Duhring, potassium iodide, benzoin, and succinic and 
tartaric acids may be excreted with the perspiration. 

Unna, following in the lines indicated by Meissner, asserts that the 
coil-glands actually produce the subcutaneous fat-cushion ; and the 
anatomical basis of such a statement is clear. The coil-glands and 
the fat-cushion appear at the same period of foetal life and develop in 
the same proportions. At birth the clusters of fat are most conspicu- 
ous where the coil-glands are most numerous. In the adult the greater 
number of coil-glands are subcutaneous in situation and are closely 
surrounded by fat-globules ; while those glands which do not descend 
below the corium, though not thus surrounded, are regularly met by 
columns of fat advancing toward them from below. The credit of 
discovering and naming these Fat-coltjmxs belongs to Warren, 
whose studies were principally directed to the anatomy of the thick 
cutis vera. 1 The back and shoulders of a vigorous adult furnish 
an integument much thicker than the hide of many pachydermatous 
animals. The papillae are imperfectly formed and are represented by 
an undulating line. The follicles of the lanugo-hairs penetrate only 
the superficial layers of the cutis. From the bases of the hair-folli- 
cles nearly vertical clefts, or slender, columnar-shaped spaces, extend 
obliquely to the panniculus adiposus. These shafts are named " fat- 
columns " or " fat-canals/' as they are entirely occupied by adipose 
tissue. (See Figs. 3 and 4.) 

The fat-columns are four millimetres in length, and are slightly wider 
than the hair-follicles above. Their long axes form a slight angle with 
that of the follicle, but they are nearly parallel with that of the erector 
pili muscle. The horizontal prolongations are given off on either side 
of the middle of this axis, partly fat-filled. Near this point the coil 
of a sweat-gland is seen to be held in place by a few delicate fibres. 
The duct of the gland runs to the top of this space, whence it may 
be traced to the side of the hair-follicle. The connective-tissue fibres 
seem to terminate abruptly at the edges of these columns. The cleft 
slightly widens below, and on the side toward which its axis leans the 
fibers of connective tissue form a bundle penetrating below to the 
subcutaneous fat. The erector pili muscle is inserted partly into the 
base of the follicle and partly into the apex of the fat-canal. These 
columns correspond in number with that of the hairs. The blood- 

1 Satterthwaite' s Manual of Histology, p. 420. New York, 1881. 



48 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



vessels they contain, which spring from the subcutaneous plexus, bifur- 
cate at the lateral clefts. Unna demonstrates that the fat-columns 
invariably. advance toward the coil-glands either singly or in groups, 
and that the connection of the fat-columns with the hair-follicles is a 
mere incident of that advance. 

The alternation of muscular fibres with the secretory cells of the 
ducts of the coil-glands is a provision for the extrusion of the gland- 
secretion onward. The same anatomical arrangement permits free com- 
munication between the epithelia and the lymph-spaces which reach 
into the connective-tissue sheath of the gland. As a result, the lymph 
flows freely among the secreting elements of the gland and its duct. 

Fig. 20. 




Thin section of the skin of a finger, removed at the site of a sweat-pore. Magnified 150 
diameters. The cavities or spaces seen in the epidermis are, some, apparently uncolored ; others 
are blackened by the action of osmic acid upon fat originally contained in either cells or spaces 
between the latter. The effect is due to excretion of fat by the coil-glands, and the condition 
shown is not exhibited in all sections of the skin made.at the same level. It is probably transi- 
tory, and is most apparent when the skin is macerated by sweat. 



This lymph, loaded with fat, streams away from the coils, and before it 
reaches the lymphatic trunks its fat-globules are filtered away in the 
subcutaneous tissue. 

Odorous Emanations from the Skin. — The skin of the human 
body in health is the constant source of odorous emanations, which, in 
pathological conditions, may greatly be increased or otherwise changed. 
The nature and exact sources of these emanations are as yet imperfectly 
understood. Were they exclusively volatile, gaseous, or vaporous, even 
though capable of condensation upon external bodies, this would scarcely 
explain the well-known fact that some of the lower animals are capable 
of tracing the track of a human being for miles over a wind-swept 
path until the soil pressed by the foot is covered with water. There 
is strong reason to believe that these emanations are vehicles by which 
certain contagious and infectious diseases are transmitted from one 
individual to another. They at times contain living matter derived 
from the protoplasm of the body, and are capable of conveying bacteria 
in compact masses and in enormous quantities through the atmosphere 
when it is agitated by a current of air. Some of the schizomycetes 



NAILS. 



49 



weigh but one-ten-billionth of a milligramme, and are transported 
through space in the most attenuated of media. These emanations are 
properly regarded as having their origin in the secreting system of the 
skin, but in what proportion the several secreting glands participate in 
their production it is difficult to establish. The sweat at times, even 
to human nostrils, exhales a distinct odor, though, as before indicated, 
to what extent this is due to the admixture of sweat with sebaceous 
material it is difficult to determine. Peculiarly fetid and disgusting 
odors occasionally originate in chemically altered sebum exuded in 
regions of the body where the influence of the sweat-secretion must 
be, from the locality under examination, partly eliminated. 

NAILS. 

Nails are dense, elastic, and translucent concavo-convex plates, or 
shells, of horny tissue, placed upon the dorsum of the terminal extrem- 
ities of the distal phalanges of the fingers and toes. They result from 
an oblique invagination of embryonal epidermis, with modification of 
the keratinization-process at the level of the invagination (Darier). 
Each nail has a free border at the distal portion of the pulp of the 
digit, with sides and proximal borders let into distinct furrows of the 
skin. The convex surface of the nail is exposed ; the concave, regard- 
ing the phalanx, is implanted upon the nail-bed beneath. 




.>_-v..V; v->- -~- 



Vertical section of one-half of nail and matrix : a, nail-substance : &. horny layer ; c, mucous 
layer; d, papillae of corium ; e, nail-furrow destitute of papillae ; /.horny layer of the ungual 
furrow rising above the nail; g, papillae of skin of dorsal surface of the finger. 



In the embryo the first change looking to the formation of a nail 
consists in a peculiar smoothness and brilliancy of the epidermis cov- 
ering the dorsum of the distal phalanges. Later, an epithelial ridge 
or line, with a groove in front of it, traverses the tip of the finger. 
Thus, three regions are defined : the region behind the ridge, the nail- 
wall ; that in the groove, the nail-bed ; and that in front of the groove, 
the pulp of the last phalanx of the digit. A collection of large prickle- 
cells at the orifice of the nail-fold soon furnishes the first trace of the 
rudimentary nail. Mature nail-cells finally push forward between the 
prickle- and horny layers of the nail-bed, which, by fan-shaped bundles 
4 



50 ANATOMY AND PHYSIOLOGY OF THE SKIK 

of follicles, is united firmly to the periosteum of the phalanx. Lastly, 
a thin plate of horny material with a free edge is visible externally in 
the fingers and toes of the newborn child. 

In the adult, what is termed the Matrix of the nail is the tissue 
from which springs the horny plate. The cells of the matrix are cyl- 
indriform below and flattened superficially, with a fibrillary structure, 
and, instead of a stratum granulosum, are supplied with a layer of cells 
of brownish color charged with a keratogenous substance. The matrix 
is separated into, first, a posterior part, filled with from three to six 
rows of papillae ; and next, in advance of this, a lenticular space with 
curved borders, the anterior limit of which corresponds with the an- 
terior border of the lunula. The area included in these two divisions 
is provided with papillae grouped in symmetrically converging ridges, 
decreasing in size as they pass forward. This forms the matrix of the 
nail. Further forward, the Nail-bed proper — in other words, the 
tissue that supports, rather than produces, the horny plate — is com- 
posed of higher ridges of papillae, the grooves and summits of which 
are covered with prickle-cells, and the height of which is uniformly 
maintained as they stretch forward toward the pulp of the finger. 

The Nail-fold, crescentic in shape, clasps the nail posteriorly and 
laterally. It is formed of connective tissue, the bundles of which are inter- 
penetrated by numerous coil-glands and fat-columns. The epidermis 
beneath the nail exhibits prickle-, granular, and horny layers. As the 
nail is gradually liberated from its bed both at the sides and point the 
cornification of the horny layer becomes more complete, so that finally, 
as the nail-plate is pushed forward, it no longer rides over the cells of 
the rete, but over a completely cornified tissue. 

If the pulp of a nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the sur- 
face of the nail, just behind its free border, a yellowish-white band, 
convex anteriorly and somewhat increasing in width laterally. This 
line is also visible when no pressure is exerted upon the digit, its 
width varying under the conditions described. This border represents 
the space in which the three layers of the epidermis from the skin of 
the point of the finger, viz., the horny, the granular, and the prickle- 
layer, successively come in contact with the under surface of the nail. 

The Lunula is the relatively light-colored space extending from the 
middle part of the nail-fold posteriorly to its well-defined convex bor- 
der in front. After artificial removal of the nail-fold the lunula is seen 
to extend to the posterior and enclosed border of the nail-plate. It, 
therefore, represents that part of the matrix of the nail not concealed 
by the nail-fold. Its color is not due to absence of vascularity, but is 
owing solely to the relative opacity of the keratogenous cells which are 
concerned in the production of the horny threads that form the nail. 

The Nail (True Nail, or Nail-plate) originates only from the 
floor of the nail-fold as far forward as the anterior edge of the lunula. 
As to its formation, it may, therefore, be imagined as springing from its 
matrix vertically in the form of an involuted, shield-shaped plate, its 
convexity regarding the proximal phalanx. It may then be viewed 
as pressed downward over its nail-bed in front, with partially unfolded 



KAILS. 



51 



edges enwrapped by the epidermis of the sides, the narrowed point 
of the shield, elongated when untrinimed, projecting at some distance 
beyond the tip of the finger. 

With this conception it is easy to understand that the nail is con- 
stituted of horny filaments, or coherent strata of cornified cells, passing 
from the matrix or floor of the nail-fold. The upper surface of the 
nail grows, therefore, from the bottom of the nail-fold ; the under sur- 
face, from the lunula ; and the intermediate layers proportionately from 
the parts between, that interlock with corresponding grooves on the 
upper face of the bed. 

Fig. 22. 




Implantation of a nail at its border : P, papillae decreasing in size toward the middle line : 
.R, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga- 
tions; R', E, epidermal layer; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.) 



Unlike the hairs, the growth of the nails, when not modified by 
traumatism or disease, is continuous and without definite limit during 
the life of the individual. The growth is from the matrix to the free 
border, more actively in the young than in the old, and in summer than 
in winter. From one hundred to one hundred and sixty days are 
required for reproduction of an entire finger-nail, and about three times 
that period for the nail of a toe. The uncut nail is produced in the 
form of an elongated, pointed, claw-like talon. 

Nails are extremely sensitive to even moderate perversion of sys- 
temic nutrition ; and either in loss of brilliancy and polish or in 
deeper structural alterations betray evidences of changes in the health 
of the individual. 



II. GENERAL SYMPTOMATOLOGY. 



In cutaneous, as in other, diseases the clinical signs or symptoms 
of a morbid process are those by which a disease is recognized alike 
by the patient and the physician. These manifestations are divided 
into subjective and objective: the former are those appreciated by 
the patient alone in consequence of his sensations ; the latter are those 
detected by the eye and the touch of another who undertakes the 
investigation of the disease. It should be remembered, however — and 
this is a matter of some importance in this connection — that there are 
manifested to the eye and touch of the patient many objective signs 
which are liable to be interpreted or misinterpreted by him, with con- 
sequences not to be ignored. 

SUBJECTIVE SYMPTOMS. 

The purely subjective symptoms of a disease of the skin are those 
manifested to the patient by sensations other than those connected with 
vision and his own sense of touch. They include sensations of itching, 
smarting, tickling, pricking, and burning ; sensations as of increased or 
diminished susceptibility to the contact of foreign bodies ; of increased 
or diminished temperature ; pain in various grades of severity ; and 
disordered sensations, such as those suggesting the crawling of insects 
over the part, the passing of currents of hot or cold vapors or liquids, 
and the compression of portions of the skin as by cords, bands, or 
closely fitting plates. The character of the subjective sensations ex- 
perienced by a patient often proves an aid to the physician in recogniz- 
ing the nature, not merely of a present disease, but also of one which 
has preceded. Thus, the sensation produced by an attack of erysipelas 
is rarely an itching, while the latter is highly characteristic of eczema 
and scabies ; the pain of zoster and the tingling of urticaria being dis- 
tinctly different, not only from each other, but also from the subjective 
symptoms named above. 

OBJECTIVE SYMPTOMS. 

The study of the objective symptoms of a cutaneous disease is of 
paramount importance. In no respect does the skilled physician so 
distinguish himself from one who is unskilled as in ability to recognize 
the typical or atypical objective features presented in diseases of the 
skin. This study is one which no diagnostician can safely neglect, and 
its rewards are precious in every department of medical science. These 
symptoms are spread before the eye, and their legibility increases with 
every hour of careful observation. 

52 



J 



OBJECTIVE SYMPTOMS. 53 

These signs of skin-disease — or, more literally, skin-injury — are 
called " lesions " (efflorescences, elements of an eruption), and it is 
usual to classify them as primary and secondary. Such division, how- 
ever, is open to criticism, since, in point of time merely, some of the 
so-called " primary lesions " of the skin become in turn secondary and 
even tertiary. Thus, a papule which might at one time be called 
" primary," may be transformed wholly or in part into a vesicle, which 
thus becomes a secondary lesion, and such vesicle again, in the evolu- 
tion of a disease, may become a tertiary pustule, and the latter finally 
may result in a quaternary crust. In the following pages these 
symptoms of skin disease are distinguished as elementary and con- 
secutive. 

Elementary Lesions. — In describing the average size of cutaneous 
lesions it is less convenient to state their measurement in fractions of 
a line or of a millimetre than to convey an approximate idea by a 
comparison with familiar objects of relatively fixed dimensions. The 
objects usually selected for this purpose, beginning with the smallest, 
are seeds of the poppy, mustard, and rape ; the coffee-bean ; the pea ; 
the bean ; the cherry ; the finger-nail ; the chestnut ; the horse-chest- 
nut ; the egg of the hen and of the goose ; the orange. To these may 
also be added the point and head of a pin. The student will find it 
useful to familiarize himself with the size of the small seeds men- 
tioned, that their names may at once suggest to him the relative size 
of the lesions with which they are compared. 

Maculae (spots, or stains) are generally circumscribed 
alterations in the color of the integument, differing in 
size, shape, hue, and duration of the dyschromia, and un- 
accompanied by elevation or depression of the skin-sur- 
FACE. 

Maculae may be due to arterial or venous hyperemia, to the escape 
of the coloring-matters of the blood into the skin, to acquired and 
congenital telangiectasis, and to pigment-anomalies. Examples of 
maculae are to be found in the exanthematous rashes (measles) ; in 
localized hyperemia of the capillary plexuses of the corium, disappear- 
ing in various degrees according to the pressure exerted on the part 
(rosacea); in visible acquired development of blood-vessels in the 
skin (telangiectasis) ; in congenital vascularization of the surface (naevi) ; 
in variously colored blood-extravasations and stases (purpura) ; in 
stains produced by contact with dyes (hand-workers in anilin) ; and 
in pigmentary changes such as those produced by solar heat (freckles) 
or by leprosy. 

Extensive non-circumscribed changes in the skin-color are seen in 
the course of several general disturbances of the economy, as in yel- 
low fever, cancer, chlorosis, albinism, Addison's disease, argyria, and 
icterus. 

Spots of various color and device are also produced by the inten- 
tional or accidental introduction of pigmented particles beneath the epi- 
dermis, as by the process of tattooing, the explosion of gunpowder, etc. 

Maculae exhibit a wide variation in color from a rosy pink to a 
chocolate brown or even a black. This difference has suggested the 



54 GENERAL SYMPTOMATOLOGY. 

employment of such descriptive terms as roseola, erythema, and 
purpura, which, unfortunately, serve to distinguish both the features 
of diseases and the diseases themselves. 

A macula which encircles another lesion, as, for example, the halo 
around a vaccine vesicle, is called an " areola." Linear hemorrhagic 
streaks are called " vibices " ; punctate and larger extravasations of 
blood are termed " petechia " and " ecchymoses." 

Papulae (papules) are solid or compressible, ephemeral 
or persistent, circumscribed projections from the surface 
of the skin, varying in size from that of a poppy-seed 
to that of a coffee-bean. 

These exceedingly common skin-symptoms vary greatly in their 
shape, color, location, career, and significance. Thus, they may be flat- 
tened at the apex, acuminate or pointed, conical, rounded, or depressed 
at the summit to form an umbilication ; they may be pale, rosy, dark 
or lurid red, purplish, or even blackish ; they may develop in transi- 
tory or persistent processes ; they may be transformed into lesions 
containing fluids ; may desiccate and furnish scales either at apex or 
base ; may degenerate into ulcers ; or may enlarge into tubercles or 
tumors ; may be scratched, torn, or rubbed so as to lose their typical 
appearance ; may come and go ; may be sensitive to sudden changes in 
the blood-current, and yet be persistent. 

The mixed forms described above are generally named vesico-pap- 
ular or papulo-vesicular, papulo-squamous, papulo-pustular lesions, etc. 

Lesions which simulate the papule, and which, though described 
under that title, really belong to another category, are the small, semi- 
solid elevations of the surface that form at the orifices of the ducts of 
the cutaneous glands and follicles. Thus, they may consist of little 
heaps of epidermis about the hair-follicles (lichen pilaris, keratosis 
pilaris), or of inspissated sebum collected in one of or in all the acini 
of the sebaceous glands (comedo). 

The concomitants of an eruption of papular type also vary. Thus, 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo), or itching of the most intol- 
erable character (eczema papillosum), or production of trifling sensa- 
tions of annoyance, as a slight burning without other subjective symp- 
toms (acne, lichen planus). 

Papules transformed into moist lesions become covered with a crust. 
Papules scratched or torn by the finger-nails usually betray the fact in 
the minute and flat blood-scales dried upon their surface. Papules which 
ulcerate may be followed by scars, and those which have undergone 
the process of involution may be followed by macular sequelae. 

POMPHI (URTICE, WHEALS) ARE MORE OR LESS TRANSITORY, 

BY RED AND WHITISH, IRREGULA 
TIONS OF THE SURFACE OF THE 
STASIS IN SPASM OF THE VESSELS, ACCOMPANIED BY A TINGLING 
OR A PRICKLING SENSATION, AND CHARACTERIZED BY RAPIDITY 
OF EVOLUTION AND FREQUENCY OF RECURRENCE. 

The typical wheal is seen in the disease known as " nettle-rash " 
(urticaria), in which closely packed, shining, roundish and whitish 



OBJECTIVE SYMPTOMS. 55 

pea- to finger-nail-sized elevations of the skin are visible, surrounded 
by a slightly rosy border. Wheals are firm to the touch, and ar- 
ranged in patches, circles, bands, gyrations, or striatums, often disap- 
pearing in a brief time and recurring with or without a renewal of the 
cause. They are occasioned by a rapid exudation of serum into the 
rete or pars papillaris of the corium. This is due to clonic vascular 
spasm, producing irregularities in the lumen of the skin-capillaries, 
under the influence of the vasomotor nerves which supply a small 
area of the superior pars vascularis of the derma. The sensations pro- 
duced are stinging, burning, pricking, and itching. Wheals are often 
surrounded by an areola. 

" Giant "-wheals are such as have the dimensions of a hen's egg, or 
cover extensive areas of integument, as, for example, the entire surface 
of a buttock or a shoulder. 

Relics of disappeared wheals are usually transitory erythematous 
maculae, but in rare cases there is left a more or less deep pigmentation 
which slowly disappears (urticaria pigmentosa). 

At times the wheal-like condition is assumed by papillae, as also by 
lesions resulting from such traumatisms as the bites of insects, reptiles, 
horses, dogs, etc. 

TuBERCULA (TUBERCLES) ARE CIRCUMSCRIBED, SOLID, GENERALLY 
INCOMPRESSIBLE AND PERSISTENT NODOSITIES OF THE SKIN, VARYING 
IN SIZE FROM THAT OF A COFFEE-BEAN TO THAT OF A CHERRY. 

It should be carefully noted that tubercles occurring in diseases of 
the skin bear no relation whatever to the nodules having the same name 
which develop in pulmonary tuberculosis. The dermatological title 
relates solely to the size of the lesion. 

Tubercles may largely be projected from the free surface of the 
integument, or be deep seated in the skin, and but a small portion 
become evident to the view externally. Their varieties as to shape, 
color, size, and other features correspond in great part with those de- 
scribed in connection with papules. They may be attached by a broad 
base to the skin, or be pedunculated, or even pendulous. Their seat is 
usually in the deeper portions of the corium or in the subcutaneous 
connective tissue. Degenerating and ulcerating tubercles are followed, 
as might be supposed in view of their volume, by considerable destruc- 
tion of tissue, and correspondingly in cases of repair by extensive 
cicatrices. Tubercles are seen in such diseases as fibroma, molluscum 
epitheliale, syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules, but the 
distinction between these two forms of lesions will better be recognized 
when attention is paid to the particular portion of the skin in which 
each takes its origin. Papules spring oftenest from the superficial 
layers of the derma ; tubercles, from the deeper layers. At times a 
tubercle may project from the surface to a less extent than a papule, 
though its larger volume is evident as soon as the skin within which 
it has developed is handled. 

Tubercles due to a cellular infiltration may cease to be circumscribed, 
and by coalescence furnish a diffuse involvement of both the skin and 
the subcutaneous tissue. 



56 GENERAL SYMPTOMATOLOGY. 

Papulo-tubercles are transitional forms assignable to either of the 
two lesions named. 

Phymata (tumores, tumors) are masses of solid tissue, or of 
solid tissue more or less commingled with fluids of variable 
consistency, differing in size, shape, color, and in the benig- 
nity or malignity of their career, located either within or 
beneath the skin, or, being attached to the skin, projecting 
from it to a variable extent. 

The mere fact that a lesion of the skin approaches in dimensions the 
size of a tumor is in itself an element of gravity. Tumors may origi- 
nate in mere hyperplasia of the living matter; may consist of new 
formations of greater or lesser danger to the vicinage or to the general 
economy ; may be formed of blood-vessels or of lymphatic vessels, or 
of both in the same lesion ; may embody large fluid-containing cysts ; 
may be built up of nerve-tissue, fat, bundles of connective-tissue fibres, 
glandular elements, and indeed of any of the elements which exist 
physiologically in the human integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

Vesicule (vesicles, PHLYCTENE, phlyctenule) are acumi- 
nate, ROUNDED OR FLATTENED ELEVATIONS OF THE HORNY LAYER 
OF THE EPIDERMIS WITH LIMPID, LACTESCENT, OR SANGUINOLENT 
FLUID CONTENTS, VARYING IN SIZE FROM THAT OF A POPPY-SEED TO 
THAT OF A COFFEE-BEAN. 

Typical vesicles are seen in the minute, transitory lesions occurring 
in the vesicular form of eczema. They are usually filled with a clear 
serum. Variations from this type, however, are common. Thus, they 
may be either flattened, acuminate, roundish, umbilicatecl, or conical ; 
may be fully distended or partially collapsed upon their contents ; may 
have a short or long duration ; may be distended with a milky, chylous, 
or blood-stained fluid ; may be opalescent, yellowish, reddish, or black- 
ish in color; several may coalesce to form a many-chambered bulla. 
One or several may undergo transformation into pustules or bulke. 
Vesicles may terminate by accidental or spontaneous rupture, their 
contents freely flowing forth upon the surface of the peripheral integu- 
ment; or they may desiccate to a crust; or may even terminate by 
one of the ulcerative processes. They may or may not be accompanied 
by pruritus. Minute vesicles, which are merely the external apices of 
large-chambered accumulations of fluid beneath, occasionally form upon 
the surface of the skin. Such are seen in the course of lymphangiec- 
tasis. 

Pustule (pustules) are circumscribed cutaneous abscesses, 
covered with an epidermal roof- wall, and varying in size 
from that of a millet-seed to that of a filbert. 

The typical pustule contains pus, and is colored yellowish, yellowish 
green, or brownish green, according to the admixture of its contents 
with blood. The pus being an inflammatory product, necessarily indi- 
cates the occurrence of an inflammatory process at the base of the 
pustule. Pustules, like vesicles, may be roundish, acuminate, globoid, 
conical, or umbilicated, and surrounded by an inflamed or normal 



OBJECTIVE SYMPTOMS. 57 

integument ; may be superficial or be deep-seated ; may terminate by 
rupture or by desiccation ; may or may not be followed by an ulcer 
and ultimate cicatrix. They may be seated either upon the free surface 
of the skin, or at an orifice of a follicle, in which case they represent 
an inflammation with purulent product in the duct or the gland 
beneath. 

Pustules may originate as such, or as a consequence of transforma- 
tion of vesicles, or after a change in a papule, which may thus come to 
have a purulent apex. According to Auspitz, they invariably originate 
from vesicles. Pustules often result in the formation of crusts, the 
latter varying in color according as the pustules from which they orig- 
inated contained a clear serum or blood. 

Transitional forms between vesicles and pustules are termed vesico- 
jiustules. Pustules of a large size, resting upon an indurated, engorged, 
and elevated base are often called "ecthymatous." 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and many 
other cutaneous diseases, including several forms of dermatitis medica- 
mentosa. Many contain pus-cocci ; some furnish a " neutral," or pseudo-, 
pus destitute of micro-organisms. 

Bullae (blebs) are superficial or deep-seated elevations 
of the skin having fluid contents, differing in color, shape, 
and career, and varying in size from that of a coffee-bean 
to that of a goose-egg. 

Blebs have been described as large vesicles ; but this fails to define 
exactly their pathological character. Like vesicles, they may contain 
serum, lymph, blood, or pus, and may variously be colored according 
to the degrees in which their contents become visible through a semi- 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, or conical, and may even exhibit angles. 
They may be seated upon an apparently unaltered or an evidently 
morbid integument ; and may or may not present a peripheral areola. 

Bullae may persist or may rupture ; may desiccate or may degenerate 
into ulcers ; may collapse after the escape of their contents, and the 
roof-wall become glued to the base from which it was originally raised. 
Bullae usually occur in extremely debilitated states of the system, and 
are, as a rule, of graver portent than other fluid-containing lesions of 
the skin. They occur in scalds and burns, in pemphigus, leprosy, 
erysipelas, syphilis, and moist gangrene. 

Consecutive Lesions. — Squamae (scales) are attached or 

EXFOLIATED EPITHELIAL LAMELLA WHICH HAVE BECOME APPRECI- 
ABLE AT THE SURFACE AS THE RESULT OF SOME MORBID PROCESS 
IN THE SKIN. 

There is constantly in progress over the superficies of the body 
physiological desquamation, the evidences of which are not pronounced 
in skins properly cleansed by ablution. In morbid processes, how- 
ever, desquamation may occur as a distinct symptom in various forms. 
Thus, the scales may be minute, fine, branny, dirty white or yellowish ; 
they may be large, pearly white, shining ; may be dry or fatty ; may 
be aggregated so as to resemble flaky pie-crust ; may exfoliate in 
extensive sheets, as from the entire sole of the foot or the palm of the 



58 GENERAL SYMPTOMATOLOGY. 

hand, or in glove-finger-like sheaths, as from the surface of a digit ; 
they may be scanty, scarcely perceptible, and so firmly attached as to 
require force for their removal ; they may fall spontaneously in a pul- 
verulent shower, being so abundant as to encumber the garments or the 
bed-clothing of the patient. 

Furfuraceous or pityriasic desquamation is that form in which fine, 
bran-like scales are shed from the surface. 

Scales are frequently intermingled with other lesions, often succeed- 
ing the latter. Thus, a papule may scale at its apex, or surround its 
base AAdth a collarette of loosened epidermal plates, beneath or between 
which a macular stain is visible. Again, scales may develop from 
macule, tubercle, or tumor. Though generally conceded to be evi- 
dences of a dry and non-discharging disease of the skin, they are at 
times accompanied or succeeded by moisture of the part aifected. 

The term scales is sometimes applied to the flattened plates of dried 
sebum that form on the scalp and on portions of the trunk in sebor- 
rhea sicca. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, and 
in several of the parasitic diseases of the skin. 

Crust^e (crusts) are relics of the desiccation of patho- 
logical PRODUCTS OF THE SKIN. 

Crusts never occur as primary symptoms of disease. When formed 
by the desiccation of serum only they are of a yellowish, straw-yellow- 
ish, or reddish-yellow hue ; when composed largely of dried pus they 
are colored greenish or greenish yellow ; and when there has been an 
admixture of blood they are usually brownish or blackish. At times 
they suggest in appearance gum, honey, or Venice turpentine; in 
shape they may have the form of the concavo-convex lid of a watch- 
case ; in color and shape they may resemble the half-shell of an oyster 
or the carapace of a small turtle. They may be delicate and thin, 
bulky and thick, friable or mealy ; may be firmly attached to the sub- 
jacent tissues or readily separable ; may cover a sound though tender 
and reddened epidermis ; may conceal a superficial or a deep, foul- 
based ulcer, by secretions from beneath which they are raised above 
the plane of the skin and increased in thickness ; they may be circum- 
scribed and no larger than a small finger-nail ; may envelop an entire 
limb or organ, as the leg or the penis ; or, finally, may be so irregu- 
larly disposed among other lesions — papules, pustules, excoriations, and 
open ulcers — that it is difficult to define their outline, or even to recog- 
nize their identity. Crusts formed of dried sebum are greasy to the 
touch, dirty yellowish in shade, and usually seated upon a non-infil- 
trated base. 

Crusts are common in eczema, syphilis, leprosy, seborrhcea, and in a 
large number of other diseases of the integument. 

Excoriations are superficial solutions of continuity, 
usually involving portions of the skin affected with pru- 
ritus, and resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin-lesions, 
possess a value from the diagnostic point of view which can scarcely be 
overestimated. They occur as striated, linear, punctate, circular, or 



OBJECTIVE SYMPTOMS. 59 

irregularly shaped, furrowed wounds, at times involving areas of flat 
surface, oozing with serum or blood, covered with dried blood or crusts, 
yellowish or reddish in hue, and for the most part both induced and 
accompanied by severe pruritus. They may coexist with hyperemia 
and infiltration of the skin beneath, brought on by the irritative char- 
acter of the continuous, or, more frequently, interrupted, cause by 
which they were begotten. 

Excoriations become significant according as they indicate scratch- 
ing, tearing, or other species of wounding by the finger-nails, and the 
rubbing of portions of the integument with foreign bodies. In the 
former case they are significantly recognized in those portions of the 
body most accessible to the hands, though in the case of eczematous 
children and infants they may originate by the rubbing together of the 
knees, or the rubbing of one leg by the feet and toes of the other leg. 
The loss of tissue may extend deeper than the rete, at times invading 
the papillae of the corium, which bleed in consequence. 

Excoriations may occur without the appearance of other lesions, as 
in the disease called " pruritus "; but where itching is severe and 
induced by a cutaneous exanthem the lesions constituting the latter 
may be intermingled with, obscured by, or even obliterated by excoria- 
tions and the pathological processes to which they give origin. Thus, 
macules, vesicles, pustules, and papules may undergo change; and the 
recognition of the type of the existing disease may correspondingly be 
difficult. Excoriations are common in skins wounded by lice, bed- 
bugs, and gnats; in the subjects of eczema, scabies, intertrigo, and 
prurigo; and in individuals with special sensitiveness of the integu- 
ment to the action of a medicament employed either internally or ex- 
ternally. 

Ehagades (fissures) are linear solutions of continuity, 
usually occurring in previously infiltrated portions of the 

SKIN. 

Fissures may extend to the derma, and invade yet deeper struct- 
ures; may be painful or the reverse; may be dry, secretory, or in- 
crusted; are often hemorrhagic, and usually are formed with sharply 
cut walls. They are of frequent occurrence in the vicinity of the 
articulations, in which situations they are induced or aggravated by 
the joint-movements stretching or tearing tissue the extensibility of which 
has been diminished by any morbid process. Fissures may terminate 
in ulceration ; they vary as to length, curve, and tenderness ; they are 
often exquisitely painful, and greatly complicate the skin-disease in 
which they form; they may follow the curve traced by the boundaries 
of bodily organs near which they occur — as, for example, the line of 
the posterior junction of the ear with the head, or that of the breast 
of a woman with the thoracic wall upon which it rests. 

Fissures occur in eczema, syphilis, dermatitis, and lichen ruber. 

Ulcera (ulcers) are losses of substance resulting from a 
previous pathological process involving the corium, and, in 
some cases, the subcutaneous tissue. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 



60 GENERAL SYMPTOMATOLOGY. 

outline, a base, a floor, edges, and a secretion. The outline may be 
circular, crescentic, reniform, ovoid, serpiginous, or with horseshoe- 
like contour. The base, or underlying tissue, may be soft, supple, 
indurated, or in a state of active inflammation, with consequent infil- 
tration. The floor may be glazed, shallow, deep, excavated, cup- or 
funnel-shaped, "worm-eaten," crateriform, sloughy, covered with a 
tenacious or a, readily removed secretion, granular, puriform, or hem- 
orrhagic. The edges may be clean-cut, having a punched-out appear- 
ance, undermined, everted, ragged, irregular, or contracting, with a 
whitish inner border of advancing cicatrization. The secretion may 
be scanty, limpid, puriform, profuse, ichorous, and odorless, or exhale 
an offensive stench. Ulcers may be so crust-covered as to be invisible, 
or so exposed and erosive in action as to render the affected surface in 
the highest degree unsightly. They may be acute or chronic, insensi- 
tive or productive of intense pain; may heal by cicatrization, remain 
open for a lifetime, or prove fatal either by destruction of parts essen- 
tial to life or by exhaustion of the vital forces. 

ClCATEICES (SCAES) AEE NEW-FOEMED SUBSTITUTES FOE LOST CON- 
NECTIVE TISSUE. 

Scars never succeed excoriations, fissures, or other solutions of con- 
tinuity in the skin that have not penetrated as far as the derma and 
resulted in destruction of a portion of the elements of which the derma 
is built up. They possess the highest importance for the diagnostician, 
since they point invariably to a pathological process the career of which 
is terminated, the characteristic features of which termination they fre- 
quently embody. They may be regarded as the special and persistent 
imprints upon the integument of the serious disorders from which it 
has suffered. 

To a certain extent, as already shown, scars retain traces of the spe- 
cial peculiarities of the lesions, and even of the diseases, which they 
succeed. The identification, however, of the individual predecessor in 
each instance is, in the present state of our knowledge, not always pos- 
sible from a study of cicatrices alone. The extent of knowledge in 
this direction, however, is rapidly increasing; and in many cases the 
certainty thus acquired is of incalculable value to the diagnostician. 

Scars are remarkable for their tendency to contraction and gradual 
decoloration. They may be minute, punctate, extensive in area, 
attached to underlying tissues, depressed, raised above the plane of the 
peripheral skin, seamed with furrows, pliable and soft, indurated, trav- 
ersed by ridges, knotted, or as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular pro- 
longations toward contiguous portions of the skin, and by subsequent 
contraction induce considerable distortion and deformity. Thus, they 
may drag down an eyelid, and ectropion ensue ; may glue the lobe of 
an ear to the cheek ; may evert lip or nostril. When recent they are 
usually reddish in tint ; when older they may be pigmented in centre 
or at circumference ; or, as is common, may exhibit a gradual decolora- 
tion centrifugal in its progress. They may be the seat of pain from 
an entrapped nerve-filament ; may reopen to ulceration ; or may be 
unaccompanied by subjective sensation, Not rarely they become the 



OBJECTIVE SYMPTOMS. 61 

source of keloid. Scars are unprovided with hairs, papillae, or the ori- 
fices of sweat-pores and sebaceous gland-ducts. As implied in the 
definition given above, scars may result from any disease or injury 
of the skin that involves loss of connective-tissue elements in the 
corium. 

Unclassified Lesions. — To the several lesions defined above Bazin 
adds, as elementary forms, the mucous patch of syphilis, the cuni cuius, 
or furrow, produced in the skin by the Acarus scabiei, and the sulphur- 
colored crusts of favus. Among the elementary lesions of the skin, 
Brocq includes the gumma, or firm, deeply situated, often subcutaneous 
mass commonly degenerating centrally rather than, as may the tubercle, 
from without inwardly ; while among the consecutive (so-called " second- 
ary ") lesions of the skin the same author considers " lichenization " or 
" lichenification." These are terms chiefly employed by French writers 
to designate the changes in the skin produced by long-continued ex- 
ternal irritation, the thickened and infiltrated integument assuming 
a yellowish-brown or reddish-brown tint, the exposed surface being 
studded with pinhead, pin-point, or slightly larger, shining and flattened 
isolated elevations, with delicate furrows separating each from the 
other. These, however, are not general, but special features of 
individual disorders, and are best studied in connection with the 
latter. 

The elementary lesions of the skin are termed by Auspitz anthe- 
mata ; groups of such lesions, synanthemata ; and, in accordance with 
common usage, generalized eruptions affecting the entire surface of the 
body, exanthemata. The word erythanthema is used to describe groups 
composed of several of the elementary lesions of the skin, as, for ex- 
ample, of papules, vesicles, and pustules rising from a common red- 
dened and hypersemic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in qualifying 
terms which here require definition. They relate chiefly to the color, 
shape, distribution, and method or period of evolution of lesions as 
they are observed in individual cases. The more important of these 
terms, as used by modern writers, are alphabetically arranged below, 
with a brief explanation appended to each. 

Abdominalis. Located on the abdominal surface. 

Acquisitus. Acquired. 

Acuminatus. Having a pointed apex. 

Acutus. Of acute course. 

Adultorum. Occurring in adult years. 

aestivalis. Occurring in the summer season. 

Aggregatus. Collected in patches. 

Agritjs. Acute, or angry in appearance. 

Albidus. Of whitish color. 

Angiectaticus. Vascularized. 

Annularis. \ T .-, r v 

Annulatus. } In the form of a rin S- 

Apyreticus. Unaccompanied by fever. 

Areatus. Occurring in areas. 

Artifictalis. Producible artificially. 

Asymmetricalis. Of different distribution on the two lateral halves of the body. 



62 GENERAL SYMPTOMATOLOGY. 

Autumnalis. Occurring in the autumn. 

Brachialis. Occurring on the surface of the arm. 

Cachecticorum. Occurring in debilitated subjects. 

Capitis. Occurring on the head, usually the scalp. 

Cavernosus. Large chambered. 

Chronicus. Chronic in course. 

Circinatus. Of circular outline. 

Circumscriptus. Having a definite contour. 

Uonfertus. \ Arranged [ n close proximity, with coalescence of lesions. 

Contagiosus. Capable of transmission by contagion. 

Corporis. Occurring on the surface of the body ; employed usually to designate an 

eruption upon the trunk, as distinguished from that on the head or the extremities. 
Crustosus. Crusted. 

Crystallinus. Of crystalline appearance. 
Diffusus. Irregularly disposed. 
Discretus. Having isolated lesions. 

Disseminatus. Disseminate ; without regularity of distribution. 
Eruption, Is used of the totality of all patches and lesions upon the person of 

one individual. 
Erythematosus. Having a reddish blush. 
Essentialis. Idiopathic. 
Exfoliativus. Having a tendency to exfoliation or shedding from the surface of 

the body. 
Exulcerans. Exhibiting lesions with a tendency to superficial ulceration. 
Facialis. Located on the face, usually as distinguished from the scalp. 
Favosa. Displaying crnsts of favus. 
Febrilis. Accompanied by a febrile process. 
Femoralis. Occurring on the surface of the thigh. 
Fibrosus. Composed of fibrous tissue. 
Figuratus. Having a figured appearance. 
Flavescens. Of yellowish hue. 
Foeiaceus. Kesembling a leaf or leaves. 
Follicularis. Concerning the cutaneous follicles. 
Fungoides. Resembling a fungus. 

Furfuraceus. Exhibiting numerous fine, bran-like scales. 
Guttatus. Of the size of a drop of water. 
Gyratus. Having a serpiginous or gyrate outline, which is usually the result of a 

coalescence of imperfect circles or semicircles. 
Herpetiformis. Vesicular or herpetic in type. 
Hiemalis. Occurring in the winter season. 
Humidus. Accompanied by moisture. 
Hypertrophicus. Characterized by hypertrophy. 
Hystrix. Having lesions projected or erected like quills. 
Imbricatus. With crusts or scales overlain like tiles. 
Impetiginodes. Pustular. 
Infantilis. Occurring in infancy. 
Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 
Labialis. Occurring upon the surface of the lip. 
Lenticularis. Of the size of a small bean. 
Lividus. Deeply colored. 
Maculosus. Discolored. 
Madidans. Characterized by moisture. 
Marginatus. Having a defined margin. 

Medic amentosus. Produced by external or (more commonly) internal medication. 
Melanodes. Of blackish color. 
Miliaris. Of the size of a millet-seed. 
Mitis. Of mild, benignant type — the reverse of agrius. 

Multiformis. Exhibiting simultaneously several types of elementary lesions. 
Neonatorum. Occurring in the newborn. 
Neuriticus. Having nervous association. 
Nigricans. Of a black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 
Nummularis. Of the size of small coins. 



OBJECTIVE SYMPTOMS. 63 

Oleosus. Accompanied by an oily secretion. 
Palmaris. Occurring on the palms. 

Parasiticus t ^ >r0 ^ uce ^ by an animal or a vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 

Phlegmonosus. Accompanied by deep-seated inflammation. 

Phlyct^enoides. Characterized by groups of small vesicles. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Belated to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous. The Greek equivalent of the Latin multiform. 

Pr^eputialis. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfaces of the genitalia. 

Pruriginosus. Accompanied by itching. 

Pubts. Located upon the skin or hairs of the pubes. 

Punctatus. Occurring in dots or points. 

Rhagadiformis. Fissured, or tending to produce fissures. 

Rosaceus. Having a rosy or pinkish hue. 

Ruber. Red ; usually dark red in color. 

Scutiformis. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis. Occurring in advanced years. 

Serpiginosus. Literally, creeping ; advancing in irregular gyrations. 

Siccus. Dry ; unaccompanied by moisture. 

Solitarius. Exhibiting an isolated lesion, or with isolated lesions. 

Symmetricalis. Similarly distributed on the two lateral halves of the body. 

Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

Universalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Variegatus. Exhibiting several distinct colors. 

Vasculosus. Accompanied by vascular development. 

Vernalis. Occurring chiefly in the spring of the year. 

Versicolor. Exhibiting several shades of the same color. 

Vulgaris. Of the usual or commonly observed type. 



III. GENERAL ETIOLOGY. 



The study of the causes of skin-diseases gives a glimpse of the eti- 
ology of diseases in general. In the lowest representatives of life the 
greatest dangers to existence originate in exposure to assault from other 
and stronger representatives in search of their prey- — in other terms, 
an external danger. In man, the highest representative of the animal* 
scale, the perils of existence are complicated by his social necessities 
and his artificial methods. He can never, however, at any period of 
his existence, divest himself from the necessity of exposure to external 
peril. The plan of his organs and the play of his normal activities are 
perfect, even to the recovery from all but mortal injury and repair of 
moderate loss. The struggle for existence of the ideal man is intended 
to be with that which is without ; his body meanwhile furnishing him 
with a comfortable tenement and a fair fortress. In the purview of 
nature there should be no internal revolt. When such occurs it is 
usually the result of his ignorance, his folly, or his vice. 

Viewed comprehensively the causes of diseases of the skin are seen 
to be numerous ; extremely different from each other ; some effective 
singly, others either alone or in combination with similar or different 
agencies ; some operating slowly, others rapidly ; some operating from 
within the body, others from without ; some directly, yet others only 
very indirectly, exerting their forces upon the integument. The results 
are as diverse as the causes themselves. Some dermatoses produced by 
a single cause are similar in symptoms ; others, originating from like 
causes, present scarcely the slightest resemblance to each other. It is 
from a study of this interesting field that much of the experience of 
the diagnostician is derived. 

For convenience of classification, it is well to consider the causes of 
diseases of the skin : first, as internal agencies ; secondly, as external 
agencies ; thirdly, as agencies which modify diseases produced by any 
of the original factors capable of their production. 

INTERNAL CAUSES. 

Heredity. — Some cutaneous disorders, such as syphilis, are capable 
of transmission to a second generation. The prevalent doctrines, how- 
ever, respecting the inheritance of a large number of cutaneous affec- 
tions are without question erroneous. Still the fact remains, that 
whether keratosis, psoriasis, and some other diseases not recognizable 
at birth (as may be the lesions of syphilis), are at times the result of 
inheritance, it is certain that a predisposition to diseases of many kinds 
is in perhaps the majority of cases transmitted to a second generation. 

64 



INTERNAL CAUSES. 65 

The weakness or vulnerability of a given organ of the body renders it 
especially liable to external or internal sources of damage, and may be 
strictly inherited. 

Sex and Age are not to be regarded as effective in the production 
of diseases of the skin, but some of the latter are conspicuously 
exhibited at certain periods of life, and others, in preponderance or 
exclusively, in individuals of one sex. Thus the several forms of 
rosacea are more common in middle life ; carcinoma in later years ; 
hydroa vacciniforme and contagious impetigo in children ; diseases of 
the nipple almost exclusively in women ; and the trade dermatoses 
largely in men. 

Visceral and Constitutional Disorders. — The group of affections 
commonly included in the language of the schools as within the field 
of " inner medicine " furnishes a large list of causes effective in the 
production of cutaneous maladies. Among visceral disorders may be 
named those of the kidneys (Bright' s disease, albuminuria, diabetes), 
giving rise to pruritus, angioneurotic oedema, eczema ; of the uterus, 
giving rise to certain pigmentary changes in the skin ; of the central 
or peripheral nervous system, as in urticaria, herpes, hemiatrophia, prur- 
itus, alopecia ; of the alimentary canal, producing eczema, acne, urti- 
caria, etc.; of the adrenals, as in morbus Addisonii ; and of the stomach, 
as in several of the gastric dyspepsias, which are capable of producing 
urticaria, erythema, acne, and rosacea. 

Among the constitutional affections capable of originating disorders 
of the skin may be named glycosuria (apart from renal diabetes), which 
may be productive of glycosuric xanthoma ; syphilis, which is respon- 
sible for an extended list of dermatoses ; gout and rheumatism, which 
influence to a remarkable degree the oncoming of certain eczemas of 
the anal and other regions, multiform erythema, acne rosacea, and 
purpura ; and disorders of the respiratory tract, some of which (e. g., 
asthma) are well known to have a distinct relation to eczematous out- 
breaks, with which their attacks may alternate. 

The Nervous System is responsible for a number of dermatoses. 
The nerve-centres, nerve-trunks, and nerve-terminals may largely influ- 
ence inflammatory, congestive, and atrophic states ; cerebral, spinal, and 
sympathetic nervous changes (trauma, new-growths, simple inflammatory 
thickenings, etc.) may be directly or indirectly concerned in attacks of 
pemphigus, zoster, scleroderma, urticaria, hyperidrosis, alopecia, and 
even grave ulceration of the skin. Pigment-changes in the skin and 
its accessories (hair and nails) have been produced by such causes. 

Psychical perturbations, as in the shock following traumatisms, ter- 
ror, bereavement, great and prolonged anxiety, and even the excite- 
ments of success in war and business have a demonstrable effect both 
on the nutrition and color of the skin and of the hairs and nails, as 
well as in the production of exanthemata, such as bulla?, vesicles, and 
several types of dermatitis. In the same connection may be named 
the results of maternal impressions upon the foetus, which, among the 
ignorant and to an extent also among men of science, are believed to 
be responsible for so-called " mother's marks," including pigmentary, 
papular, and vascular nsevi, as well as the larger lipomatous tumors 
5 



66 GENERAL ETIOLOGY. 

associated with hairy moles. The disorders designated "hysterical 
neuroses " constitute a small group of affections occurring chiefly in 
young and hysterical women, characterized by the occurrence of vesic- 
ular and bullous lesions, some taking on a gangrenous aspect, others 
exhibiting oddly arranged and defined streaks of dermatitis, to which 
latter the suspicion justly attaches that the lesions have been in great 
part produced by the patients themselves. 

The Sexual System of both men and women, especially in young 
subjects, may be a source of cutaneous disorders. Among them may 
be named the seborrheas, acnes, and comedones, often aggravated by 
menstruation and by perversion of function in both sexes, progenital 
and menstrual herpes, pemphigus virginum, and certain of the erythem- 
ata. The several cutaneous affections recognized in the pregnant con- 
dition are often unquestionably associated with the condition of the 
gravid uterus. Of these, the most common are scarlatiniform erythema, 
impetigo herpetiformis, dermatitis herpetiformis, and verruca? of the 
vulvar region. 

Auto -infection. — This is a field of investigation the confines of 
which have been barely touched by the explorations of modern science. 
At present it is demonstrable merely that the alimentary tract is trav- 
ersed by innumerable micro-organisms which are wholly innocuous. 
Under certain favoring conditions, however, these germs may either be 
commingled with others introduced from without, and thus become in 
various degrees dangerous to the economy from slight perversion of 
health to actual destruction of life in a relatively brief period of 
time ; or the innocuous parasites with and without the cooperation of 
the toxins they engender may suddenly become inimical to health from 
a change in their condition. 

Ingesta. — Food and medicines are responsible for many cutaneous 
lesions in consequence, first, either of an inherent toxic quality in the 
substance ingested ; or, secondly, in consequence of a special irritability 
of the alimentary canal existing at the time of such ingestion, the 
cause of the disorder being at other times ineffective. 

Among the foods capable of producing urticarial distress may be 
named shell-fish, the smaller berries having seeds, cheese, pickles, 
oatmeal, buckwheat, mushrooms, olives, the skins and seeds of grapes 
and of oranges, and certain kinds of fish, as well as alcoholic bever- 
ages. A large list of medicinal substances is enumerated in the chap- 
ter on Dermatitis Medicamentosa which are capable of producing skin- 
eruptions. Among these may be named, as illustrative of the group, 
the salts of bromine and of iodine, arsenic, quinine, copaiba, belladonna, 
and a number of the new remedies produced by the action of glacial 
acetic acid upon the petroleum-products, such as antifebrin and phe- 
nacetine. 

The Physiological Crises are not in themselves primary causes 
of dermatoses, seeing that the larger number of all members of the 
human family survive them without harm to the skin. It is none 
the less true that they furnish influences which modify and at times 
invite exanthemata. The possibilities of the pregnant state in con- 
nection with cutaneous disease have already been explained. Denti- 



EXTERNAL CAUSES. 67 

tion is a period in which the child often is tormented by an eczema 
displayed in greatest profusion over the cheeks; and the puberal 
epoch of both sexes is one in which are manifested many of the dis- 
orders related to the repression, perversion, or excessive indulgence 
of the sexual function. Many of the chloasmata are conspicuous in 
women at the time of the menopause ; and this also is a period in which 
may be recognized irregularities in the performance of the sweat-func- 
tion as well as in the subjective sensations experienced in the skin. 

EXTERNAL CAUSES. 

Innumerable agencies operate from without capable of exciting or 
aggravating cutaneous affections : in fact, it may be set down that few 
if any of the forces operating externally upon the skin from the begin- 
ning to the end of life may not exert an unfavorable effect upon it if 
their operation be excessive, untimely, or associated with other exter- 
nally operating factors. Briefly, some of these agencies operate singly ; 
others in cooperation ; some operate with grave, others with trifling 
effect ; some invariably, others but rarely, induce a deleterious effect 
upon the skin ; some, though exerting an influence wholly external to 
the skin-surface, cooperate with internal agencies. In the latter class 
may be named the hand of the syphilitic subject, which may exhibit 
syphilodermata largely due to the influence of the articles handled 
in the trade or occupation of the subject of the disease. 

Scratching is a fruitful source of cutaneous trouble either when 
operating to originate or to aggravate an exanthem. Its symptoms are 
carefully studied by all diagnosticians, as they betray evidences of 
itching, which the efforts at scratching are exerted to alleviate. 
The regions most affected when scratching is severe (as in prurigo, 
scabies, pediculosis, and the forms of pruritus dependent upon visceral 
disease, such as glycosuria, tuberculosis of the adrenals, etc.) are, as a 
rule, those most readily reached by the hands either of an infant or 
an adult. In these parts may then be recognized the excoriations, fre- 
quently in two, three, or four parallel or approximated lines, blood- 
specks, pustules, papules, thickening, and even extreme induration and 
pigmentation of the skin, due solely to the traumatisms of the surface 
of the integument. 

Solar Light and Heat, and Thermal Changes (whether due to 
solar or artificial influence, as well as cold), are frequent and efficient 
sources of damage to the skin from the slightest grade of inflam- 
mation to the severest destruction. To solar light is to be attrib- 
uted the production of freckles, tan, and other pigmentations of the 
surface ; to heat are to be attributed the erythema, the eczema, and 
the various grades of dermatitis which may follow exposure to the di- 
rect rays of the sun. Other temperature-effects, including those pro- 
duced by extremes of both heat and cold, are to be classed in the same 
category. Exposure of the skin to a temperature of over 100° F. pro- 
duces merely a transient erythema, which under a further elevation of 
sixty-five degrees will not subside for several days. At a temperature 
of 212° F. all grades of acute dermatitis are awakened, with the pro- 



68 GENERAL ETIOLOGY. 

duction of bullae, up to the point at which complete destruction of the 
integument occurs. 

The Influence of the Seasons is of the same general character. 
Some cutaneous diseases are worse in summer; others in winter. 1 
Prickly heat (lichen tropicus) is peculiar to certain warm seasons ; 
frostbite, with its subsequent hyperemia, exudation, or gangrene, occurs 
in winter; pruritus is common in cold weather; erythema multiforme 
is most frequent in the autumn and in the spring. 

Exposure of the Skin to the X-rays, not merely in securing 
skiagraphic results, but in the modern methods of treatment by radio- 
therapy, may produce an inflammation of the skin and of the structures 
beneath. 

Climate has a determining influence upon many cutaneous dis- 
orders, and this of a sort which it is difficult to assign either to 
internal or external influence. The effects of climate are exceedingly 
complex, and include the agencies which favorably or unfavorably affect 
the health in the direction of atmospheric humidity or dryness ; abun- 
dance or scarcity of sunlight; the prevalence of favoring or injurious 
winds and storms ; a salubrious or insalubrious food- and water-supply ; 
the average temperature of the earth's surface by day and by night ; 
the presence or absence of sources of malarial plasmodia ; and proxim- 
ity to the sea, to mountain regions, or to extensive growths of pine 
forests. Thus leprosy, Lombardy erysipelas (pellagra), biskra bouton, 
ainlrum, and other affections, though not seen exclusively in one coun- 
try, are for the most part prevalent in countries which may well be 
contrasted with others where such affections are regarded as curiosities. 
Mycetoma, for example, has been studied for the most part in India, 
while less than half a dozen cases of that disorder have been recognized 
in the North American continent. 

Occupation. — Many dermatoses are due exclusively to the occu- 
pations of men and women. In France, where such occupations 
are highly specialized on account of the artistic and skilled work 
of the people in numerous lines, these disorders are known as the 
"professional dermatoses," and the diagnostician there is often en- 
abled to decide the character of the work performed by the laborer on 
inspection of his hands. The workers in dyes, in chemicals, and in 
drugs suffer in one way ; the men who handle tiles, bricks, mortar, 
or clay in another ; the baker, the confectioner, the cook, the laundress, 
the green-grocer, the seamstress, the shoemaker, the carpenter, and the 
machinist have each their forms of erythema, dermatitis, keratosis, 
or induration. Similarly those whose faces are much exposed, as the 
wheelmen of vessels, tram car-drivers, locomotive-engineers, and day- 
laborers, exhibit symptoms in that region. Butchers, wool-workers, 
cattle-men, and sheep-shearers are liable to contract glanders, ring- 
worm, or malignant pustule. They who handle the bodies of the dead 
are prone to tuberculosis of the hands (anatomical tubercle), and those 

1 Of. Hyde, " On Affections of the Skin Induced bv Temperature Variations in Cold 
Weather,"*Chicago Med. Jour, and Exam., 1885, 1.. p. 187, and 1886, lii.,p. 116 ; Corlett, 
Jour. Cutan. JDis., 1894, xii., p. 457, and Jour. Amer. Med. Assoc, 1902, xxxix., p. 
1583. 



EXTERNAL CAUSES. 69 

compelled to stand much of the time are exposed to the consequences 
of varicose veins of the legs and resulting eczema of that region. 

Clothing. — The coarse clothing worn by the poorer classes is often 
a source of skin-mischief, particularly when employed for infants ; and 
persons of both sexes and all ages exhibit marked results from the 
wearing of flannel next the skin. Often the influence of clothing is 
commingled with that of dyes, as when brightly tinted flannel colored 
with anilin produces a dermatitis of high grade with distinct staining 
of the skin over which such clothing has been worn. In the same list 
must be included the effects produced by ill-fitting shoes, corsets, 
trusses, napkins, " pads," supporters, crutches, orthopaedic apparatus, 
hat-bands, stockings, garters, and chest-protectors. Here, too, more 
than one cause may be efficient in the production of disease, as when 
clothing becomes a nidus for parasites, or is worn next the skin when 
soiled with abnormal or even physiological secretions. 

Chemical, Medicinal, and Mechanical Irritation may be respon- 
sible for many affections of the integument. Of articles effective in the 
first category, may be named the stronger acids and alkalies ; of those 
in the second class, arnica, croton-oil, mustard, cowhage ; of those in 
the last class may be suggested all substances capable of exerting 
undue friction upon the surface, such as pumice-stone, combs, brashes, 
towels, and the articles employed in the operations of the manicure. 

Filth is a potent factor in both the production and the aggravation 
of skin-diseases, its effects being decidedly most apparent in patients 
applying to the public dispensaries. In infants the skin unwashed 
even for a fortnight usually becomes the seat of an irritating urticaria. 

Traumatism plays a most important part in cutaneous etiology. It 
includes the action, in scratching, of the nails, the knees, heels, elbows, 
etc., as well as the influence of several articles used for the same pur- 
pose — pieces of cloth of various kinds, etc. In this way excoriations, 
and even infiltrations, of the skin are induced. Under the head of 
traumatisms should be considered also injuries of the skin-surface pro- 
duced by animals, occasionally with the added effect of a toxicant. 
Here are included the wounds produced by lice, fleas, bugs, and acari ; 
the bites of serpents, horses, dogs, and cats ; and the accidents produc- 
ing traumatism of every kind, not omitting the intentional wounds in- 
flicted by the surgeon and their results. 

Transmission by Contagion, by Infection, and by Parasites. — 
Some disorders with cutaneous phenomena are transmissible from dis- 
eased to healthy persons through the medium of the atmosphere, and 
are termed infectious; others are termed contagious when transmis- 
sible solely by contact. Some maladies, such as variola, scarlatina, and 
measles, are conveyed by both methods, and hence belong to the cate- 
gory of both contagious and infectious disorders. Yet others are 
transmissible only through infection with a specific virus ; such dis- 
eases are syphilis and lepra. By many writers the terms infectious 
and contagious are used as synonyms. 

Many disorders are transmitted by the medium of insects (particu- 
larly the fly and the mosquito), which attack the skin and deposit in 
the solutions of continuity which they produce, bacteria or other 



70 GENERAL ETIOLOGY. 

noxious germs derived from foreign bodies on which they previously 
have alighted. 

Parasitic Diseases. — Under this title were once included solely the 
dermatoses induced by the presence of the animal and vegetable para- 
sites. Among the former may be named scabies and pediculosis ; 
among the latter, ringworm of the scalp and of the beard. But the 
term parasite has acquired a much wider scope since the recognition of 
the micro-organisms which have been demonstrated to be efficient in 
the production of a long list of cutaneous affections. Among these may 
be named the bacilli productive of cutaneous tuberculosis and of 
lepra ; the pus-cocci, responsible for the several forms of impetigo and 
pustular eczema ; and the streptococci, recognized in several forms of 
dermatitis. In most of the dermatoses which are recorded to-day as 
parasitic, germs have been recognized, which either singly or in coop- 
eration with others have been proved to be effective in the production 
of these disorders, or have been demonstrated to play an active part 
in either their extension or exacerbation. 

The popular ideas respecting the frequency and danger of contagion 
in diseases of the skin are often erroneous. The non-parasitic affec- 
tions are, and probably always will be, more numerous than all others. 
The danger of communicating scabies, syphilis, and other affections by 
handshaking is not as great as is generally believed. On the other 
hand, the dangers which by the mass of people are little considered 
are often the graver and more to be avoided. Among these may be 
named the use in public of the roller-towel, the drinking in common 
from public cups and glasses, promiscuous kissing, contact with the 
lower animals exhibiting diseases of the hide, of fur, or of feathers, the 
Avearing of a stocking on one foot which the day before was worn over 
the surface of a fellow-member the seat of disease, and the wearing of 
velvet- or fur-trimmed collars on top-coats after the occurrence of a 
disease of the skin of that part of the neck with which the garment is 
naturally brought into contact. 






IV. GENERAL PATHOLOGY. 1 



The pathological processes occurring in the skin are similar in 
many diseases to those occurring in other organs ; but owing to com- 
plicated structure and functions the integument has a pathology peculiar 
to itself. Various pathological conditions, such as inflammation, hyper- 
emia, anaemia, hypertrophy, atrophy, degeneration, and neoplasms, are 
found in the skin, as in other organs of the body. Some diseases, such 
as the toxic erythemas, are merely cutaneous manifestations of an 
internal disorder which often exhibits no demonstrable internal lesions ; 
in others, such as lupus vulgaris, all the pathological and clinical 
manifestations are limited to the skin. Again, in diseases such as 
syphilis similar pathological changes may be noted both in the internal 
organs and in the skin. 

Bacteria. — The skin furnishes a habitat for a large number of 
bacteria, both pathogenic and non-pathogenic. From the normal skin 
may be collected a number of varieties of cocci, bacilli, and yeasts. 
Many diseases of the skin are demonstrably of bacterial origin, while 
others are probably due to specific micro-organisms not yet recognized. 
Schizomycetes (tuberculosis, leprosy), streptotrichee (actinomycosis), 
blastomycetes (blastomycosis cutanea), hyphomycetes (favus, " ring- 
worm "), are all concerned in the production of diseases in the skin or 
its appendages. Animal parasites are responsible for several disorders 
(scabies, pediculosis). 

Hyperemia in the skin may be active or passive, local or general, 
transient or persistent. On account of the conditions which may be 
associated with hyperemia it plays an important part both in cutaneous 
and general pathology. Galloway has recently emphasized the im- 
portance of erythema as an indicator of disease. 2 

Anaemia may be general or local. It is not a frequent factor 
in the production of cutaneous disease. Generalized anemia is a 
symptom of several diseases of the blood. Local anemia occurs in 
Raynaud's disease. Local, transient anemia occurs in urticaria and 
when cold is applied to the integument. 

Inflammation. — Some of the many phases and pathological changes 
of the process recognized as inflammation are present in the majority 
of cutaneous diseases. Primarily, there occurs vascular dilatation, 
with leucocytic infiltration and exudation of plasma. The leucocytes, 

1 This section is based largely on notes taken by Dr. O. S. Ormsby during a course 
in histopathology of the skin given by Dr. MacLeod in 1900-1, in the laboratory of 
Charing Cross Hospital, London. For a complete presentation of the subject of the 
pathology of the skin, see Unna, Histopathology ; Darier, La Pratique Dermatologique, 
pp. 67-136 ; MacLeod, Pathology of the Skin. 

2 Brit. Jour. Derm., 1903, xv.*, p. 235. 

71 



72 GENERAL PATHOLOGY. 

attracted by positive chemotaxis to the point of irritation, either remove 
the offending material, micro-organisms, etc., by phagocytic action, or 
themselves are overcome, undergo fatty degeneration, and become con- 
verted into pus-cells. The chemotactic agent may be a mechanical, 
chemical, or thermic irritant, or its cellular products. The toxins of 
micro-organisms may be effective. The plasma dilutes the toxins, and 
by depositing fibrin through the action of a ferment helps limit the 
process. Varying with the degree of the reaction and its attendant 
conditions, numerous secondary epidermal changes occur. 

Histology. — The epidermis and corium, being unlike in develop- 
ment and structure, undergo different pathological changes. 

The epidermis is composed of epithelial cells in various stages of 
evolution, from the columnar, nucleated, and comparatively highly 
differentiated cell of the basal layer of the rete mucosum, to the flat 
and lifeless external cells of the stratum corneum. A knowledge of 
the normal process of evolution of these cells is necessary to an under- 
standing of the changes which necessarily must occur in disease con- 
ditions when the normal course of evolution is interrupted by some 
mechanical, chemical, microbic, or other agency. Each cell progresses 
from the basal layer of the rete through the several strata above until 
it reaches the superficial part of the stratum corneum, having on its 
way passed through various stages, and performed different functions. 
After completing its cycle of existence it is finally cast off. 

In the basal layer are situated the mother-cells of the epidermis. 
They are columnar in shape, contain nuclei and pigment, receive the 
termination of non-medullated nerve-fibrils, and have extending from 
them prolongations of protoplasm called prickles. As they progress 
upward through the rete they become gradually flattened, no longer 
contain pigment (in the white races), and on reaching the granular 
layer are filled with granules of keratohyalin, upon the perfect forma- 
tion of which depends the normal process of cornification. Further 
up, the cells become homogeneous and lose their keratohyalin, but 
acquire eleidin in the stratum lucidum. In the lower part of the 
stratum corneum their nuclei disappear and a horny substance, termed 
keratin, is formed, to which substance this layer owes its hardness. 
Here also some fat appears. Still more externally, the cells become 
entirely flat and lifeless, and eventually are shed. 

Hyperkeratosis — Acanthosis. — One or all of the layers of the 
epidermis may be involved in pathological processes depending upon 
the character of the change and its cause. When there is overgrowth 
(hypertrophy), either local or generalized, of the stratum corneum, it is 
designated as a hyperkeratosis, examples of which are seen in kerato- 
dermia and ichthyosis. 

By acanthosis (Unna) is meant a benign hypertrophy of the rete, 
in which the fibrillary structure of the cell is retained. Acanthosis 
occurs in all the infective granulomata, including syphilis and tubercu- 
losis. Malignant hypertrophy of the rete occurs in epithelioma, in 
which affection the normal rete-pegs not only are enlarged and elon- 
gated (acanthosis), but there are also rupture of the basal layer, and 
irregular infiltration into the corium of epithelial cells, which lose their 



GENERAL PATHOLOGY. 73 

fibrillary structure and often become so changed as to resemble cells 
of mesoblastic origin. 

Atrophy of the cells of the epidermis occurs under various condi- 
tions. It may be caused by pressure, either external, as from a truss ; 
or internal (neoplasm beneath the skin). It is found commonly in the 
senile skin, and is marked in cases of diffuse idiopathic atrophy of 
the skin. 

Parakeratosis, Vesicles, Bullse, and Pustules. — (Edema occur- 
ring in and between the rete-cells interferes with the formation of 
keratohyalin in the granular layer, causes the cells of the stratum 
corneum to appear swollen and moist and to retain their nuclei, and 
prevents the formation of keratin. This condition is termed "para- 
keratosis" (Unna), and is found in typical development in eczema and 
psoriasis. When the oedema becomes greater, collections of fluid form 
usually in the rete, and thus vesicles are produced. They are called 
"•parenchymatous" when the early oedema is intracellular, or "inter- 
stitial " if it be intercellular. Vesicles may be located superficially in 
the rete, as they usually are in eczema ; or deeper, as in dermatitis her- 
petiformis ; or beneath the epidermis, as occasionally happens in herpes 
zoster. Vesicle-formation is dependent not only on the mechanical 
separation of the cells by oedema, but also upon the presence of toxic 
and other substances in the lymph, which may produce separation and 
disintegration of the epithelial cells, and thus leave spaces. Bullae sim- 
ilarly are formed and located, and differ from vesicles chiefly in being 
larger. A typical bullous disease is pemphigus. When a large number 
of leucocytes collected in a chamber by chemotactic or other action, 
have undergone fatty degeneration, the lesion becomes a pustule. 
When oedema is long persistent, such as occurs when the leg is the 
seat of varicose veins, the epidermis is destroyed entirely and ulceration 
results. 

Epithelial Degeneration. — The cells of the epidermis are subject 
to degenerative processes, the one most studied being of the " hyaline " 
type. This occurs in carcinoma and also in several other diseases, but 
is not, as once was believed, pathognomonic (see cellular degenerations 
of the corium). Degeneration occurring in epithelial cells exposed to 
.r-rays, though not definitely classified, is pronounced and important. 
The nucleus as well as the cellular protoplasm is affected. The cell is 
swollen, stains poorly, becomes vacuolated, and eventually completely 
disintegrates and is carried away by leucocytic action during the period 
of reaction. 1 

Fibrous and Cellular Structure of the Corium. — The corium is 
mesoblastic in origin, and is composed of fibrous tissue and cellular 
elements. Commonly the white fibrous bundles now are termed col- 
lagen, while the yellow elastic fibres are termed elastin. The cells 
found normally in the corium are connective-tissue, mast-, and vacuo- 
lated cells. As cellular pathology is so important in cutaneous dis- 
ease, some knowledge of the minute structure of the normal and patho- 
logical cells is essential. 

1 Scholtz, Archiv, 1902, lix., pp. 87 and 241 (abstr. in Brit. Jour. Derm., 1902, 
xiv., p. 397). 



74 GENERAL PATHOLOGY. 

The common types of connective-tissue cell are large, spindle-shaped 
cells, which vary both as to size and shape. They have extending 
processes, which connect with those of neighboring cells. The nucleus 
is surrounded by a membrane, is usually either oval or round in shape, 
and is said to be vesicular on account of its open appearance, which is 
due to large spaces found between the chromatin threads. This open 
structure causes it to stain less deeply than the more compact nucleus 
of the mononuclear leucocyte, with which it often is confounded. In 
young connective tissue the cells are small and more or less oval, have 
a nucleus as above described, are surrounded by cell-protoplasm, and 
are termed fibroblasts. Other and less common varieties of connective- 
tissue cells are described by Unna as plate-cells. 

Vacuolated cells of the corium have nuclei similar to those of the 
ordinary connective-tissue cells. The cell-protoplasm presents spaces 
or vacuoles, but has no processes extending from it. On account of 
mitoses occurring in these cells, and because their apparent function is 
that of reproduction and not of evolution into connective tissue, Mac- 
Leod suggests that these may be the mother-cells of the corium, being 
thus analogous to the cells of the basal layer of the epidermis. 

Mast-cells in the corium resemble other connective-tissue cells, but 
differ from them in that they contain a number of basophilic granules. 
They are discussed more fully with the pathological cells of the corium. 

Pathological Cells of the Corium. — Plasma-cells. — Before 
Unna described the cell now generally recognized as the plasma-cell, 
at least two classes of cells were so denominated. The term is now 
restricted to cells which vary in size from that of a leucocyte to that 
of a cell two or three times as large. They are rounded or oval in 
shape and contain a large amount of protoplasm. The nucleus is usually 
eccentrically placed and corresponds in shape to that of the cell. It 
may be vesicular in appearance, or again several deeply stained masses 
of chromatin may be arranged about its border. Two nuclei are occa- 
sionally present. A cell having a similar nucleus, but containing a 
small amount of protoplasm, is found abundantly in tuberculosis, but 
is considered by many to be a lymphocyte. Plasma-cells are found 
abundantly in the infective granulomata, and to these cellular infil- 
trations Unna applied the term granuloma. Unna maintains that 
plasma-cells originate from connective-tissue cells, while Jadassohn, 
Councilman, Krompecher, Schottlander-Vmarschalko, and others be- 
lieve that they arise from leucocytes. Krompecher, Vmarschalko, and 
others agree that these cells evolve into connective tissue, thus admit- 
ting the formation of connective tissue from leucocytes. 1 Plasma-cells 
are studied best when stained with polychrome-methylene-blue (Unna) 
or Pappenheim's compound stain of pyronin-methyl-green. In the 
former, metachromatism is shown by the nucleus taking a blue color, 
while the protoplasm is stained a blue violet. 

' For full consideration of the cells of chronic inflammation, including plasma-cells 
and mast-cells, the reader is referred to a critical review of the literature by Williams, 
Amer. Jour. Med. Sci., 1900, cxix., p. 702 ; a series of papers by Pappenheim, and by 
Almkvist, Monatshefte, 1901-2 ; Maximow's monograph, Ziegler's Beitriige, Suppl. v., 
1902 ; and a review of the subject by Whitfield, Brit. Jour. Derm., 1904, xvi., pp. 7 
and 63. 



DEGENERATIONS OCCURRING IN THE CORIUM. 75 

Other important cells are Giant-cells. These occur in typical 
development in tuberculosis, but are found to a degree in syphilis, 
and cells resembling them may be noted in several chronic inflam- 
matory diseases of the skin. The tubercular giant-cell may be round, 
oval, or irregular in shape, depending somewhat on its surroundings, 
as the presence of collagen, elastin, etc. They vary in size from two or 
three to many times the dimensions of a leucocyte. They contain 
nuclei which are similar to those of plasma-cells ; and which may be 
arranged at one or both ends or sides, or completely round the peri- 
phery of the cell, and may number from a dozen or less to more than 
a hundred in a single cell. They stain deeply, thus making a contrast 
with the poorly stained centre of the cell, which presents a homoge- 
neous protoplasm. As to their origin, several theories are advanced. 
One is that they are formed by the rapid proliferation of the nuclei in 
a single cell without corresponding division of the protoplasm. A 
second is that a number of cells surround some irritant, such as tubercle 
bacilli, and coalesce, thus producing the multinucleated giant-cell. 
The question whether the giant-cell originally comes from connective- 
tissue cells or from leucocytes cannot be answered until the origin of 
the plasma-cell has been determined. 

Mast-cells. — These occur to some extent in the normal corium, 
and are found in increased numbers in some diseases, including the 
infective granulomata, in which they are not specially significant. 
In urticaria pigmentosa, however, their increase is so marked as to be 
pathognomonic. They may be produced rapidly, as was demonstrated 
by Gilchrist, 1 who noted that they formed synchronously with an urti- 
carial wheal. They may assume the shape of a connective-tissue cell, 
plasma-cell, or lymphocyte, and may originate apparently from any 
cell found in the corium. Their chief characteristic is the presence of 
basophilic granules in the protoplasm. Mast-cells of the corium cor- 
respond in staining reactions to Ehrlich's mast-cells of the blood, but 
it does not follow that those present in the cutis come from the blood. 
They are demonstrated best by stains having metachromatic properties, 
such as polychrome-methylene-blue (Unna), which stains the nucleus 
blue and the granules red. 

Degenerations Occurring in the Corium. — Hyaline degeneration 
similar to that occurring in epithelial cells in carcinoma is found also 
in the corium in sarcoma, in rhinoscleroma, in syphilis, and in other 
affections. It produces a homogeneous material in the cellular proto- 
plasm, which is acidophilic in reaction and, owing to its semifluid char- 
acter, forms round globules. Hyalin is stained orange-red by Van 
Gieson's method. 

Fatty Degeneration is found in several conditions in the skin, 
and is well represented in xanthoma. Here it is found as variously sized 
granules within a large cell, known as the xanthoma-cell, which is charac- 
teristic histologically of the disease. This cell is the product of a con- 
nective-tissue cell in the multiplex varieties, while, according to Pollitzer, 2 
in eyelid xanthoma it results from degeneration of muscular tissue. 

1 Johns Hopkins Hosp. Bull., 1896, vii., p. 140. 

2 Jour. Cutan. Dis., 1897, xv., p. 367 ; N. Y. Med. Jour., 1897, lxv., p. 679. 



76 GENERAL PATHOLOGY. 

Mucoid Degeneration is found in the " Mikulicz cells" of 
rhinoscleroma and in the lepra-cell of lepra. In both it occurs as a 
homogeneous mass, within which the specific bacilli are found. 

(Edematous Degeneration occurs in the cells of the corium, 
which is the seat of marked oedema. They appear swollen, stain 
poorly, and contain fluid. This form of degeneration is seen in tissue 
reacting after exposure to actinic and Rontgen rays. 

Crenation-degeneration is found in mycosis fungoides, and is 
evidenced by the cell becoming irregular and toothed. Eventually the 
cell entirely disintegrates. 

In addition to the cellular degenerations described above, several 
degenerative processes occur which affect the collagen and elastin. 

Myxomatous Degeneration, in which a peculiar jelly-like sub- 
stance containing mucin results from collagenous degeneration, is found 
in sarcoma and myxoedema. This substance is basophilic in reaction 
and is stained by any of the metachromatic dyes. 

Colloid Degeneration in the skin is comparatively rare. It 
occurs in the disease termed colloid milium. It consists of a homoge- 
neous degeneration of the fibrous elements of the corium. The exact 
chemical composition of the colloid material is not known. It is stained 
yellowish-red by Van Gieson's method. 

Other degenerations occur in the corium, in which collagen and 
elastin are concerned, and these are demonstrated chiefly by the stain- 
ing methods described by Unna, 1 and are termed basophilic collagen, 
collastin, collacin, and elascin. 

1 Monatshefte, 1894, xix., p. 465. 



V. GENERAL DIAGNOSIS 



The establishment of an accurate diagnosis in cutaneous diseases is 
essential to their successful management. This statement is rendered 
necessary in this connection by the prevalence of a belief among the 
uneducated that the disorders of the skin, exhibited for the most part 
in visible symptoms, can safely be treated on general principles with- 
out a recognition of the nature of the malady. By many practitioners 
the demand for an accurate diagnosis is ignored in consequence of a 
too general impression that the desired end is to be pursued through 
great and perplexing obscurity. Yet with patience, method, a habit 
of careful observation (without which no physician is successful), and 
a reasonable degree of skill both practitioner and student can, in the 
large proportion of all cases, attain their purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of an affected portion of the integument to the 
eye of him who is consulted with a view to its relief. The physician 
is supposed to inspect this surface attentively for a few moments, and 
then to pronounce definitely upon the nature of the disease present 
and the therapeutic measures to be adopted. While such a procedure 
is possible to the expert in a limited number of cutaneous disorders, in 
a large number of cases far more than this is requisite, and, indeed, 
is fully as essential here as in the investigation of disease involving 
any other organ of the body. 

It is true that erythema, urticaria, dermatitis, eczema, purpura, 
alopecia, and many other affections of the skin may often be recognized 
after simple and brief inspection of the region involved ; but the cause 
of such disorders and their relation to the general health of the patient, 
all of which knowledge is essential to their proper treatment, can only 
be obtained after a much more thorough examination. As a rule, it is 
desirable, first, to secure a history of the physical and mental condition 
of the patient in the past; then should follow the special history of the 
disorders of the skin; lastly, an examination of the patient and of the 
affected integument. The family history may be of value in making a 
diagnosis. For the purpose of methodically arriving at these facts, 
and of preserving them for future reference, they should systematically 
be recorded. The following are some of the points upon which it will 
generally be found useful to secure information : 

The name, residence, age, sex, occupation, and married or unmarried 
state of the patient should be known, as also, whenever practicable, 
the health-history of parents and children. In the case of women it 
is not only necessary to learn the history of the menstrual function in 
the past, but it is of the highest importance to be informed also as to 

77 



78 GENERAL DIAGNOSIS. 

the previous occurrence of abortions and miscarriages, and, if such 
have occurred, the order observed by these with relation to the birth 
of viable infants. The significance and value of several of these facts 
have been described in the chapter on Etiology. With respect to the 
history of the products of conception, it should never be forgotten 
that it has a most important bearing upon the question of syphilitic 
infection. The absolute exclusion of syphilis in any obscure case is a 
long step in the direction of an accurate diagnosis. In the instance 
of male patients, questions will usually elicit either admission or denial 
of the fact of a precedent or present venereal disease, and the answers 
should be regarded as valueless or trustworthy according as they are 
or are not substantiated by corroborative clinical facts. 

Then should follow some record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear, and the dates of occurrence, recurrence, and con- 
valescence be at least approximately discovered. The patient should 
also make known whether he has had refreshing sleep ; whether he has 
undergone mental anxieties (domestic, financial, etc.) ; whether he has 
suffered in his digestive, respiratory, circulatory, genito-urinary, or 
nervous system. Defects in elimination, assimilation, and nutrition 
should be noted ; and when the symptoms suggest disease of other 
organs than the skin the patient should be subjected to the proper 
physical examination. 

This much ascertained, the patient should be encouraged to narrate 
as succinctly as possible, and as far as may be in his own terms, the 
history of the present cutaneous disorder. A systematic series of 
questions put by the examiner should disclose, if possible : the cause 
of the disorder ; its appearance when first seen, and any changes in 
character and type which have since occurred; the regions of the 
body affected, in order of involvement ; the method of extension, by 
peripheral enlargement of the early areas, or by the appearance of new 
lesions at a distance from the first ones ; the rapidity and regularity of 
the progress of the disease and its duration ; the subjective sensations ; 
and the influence of seasons and temperature upon the disorder. The 
treatment to which the disease has been subjected should then be de- 
tailed, this frequently furnishing a key to the diagnosis and therapy 
of the malady. In an incredibly large proportion of all cases ignor- 
antly directed and vicious internal or external medication has either 
begotten or aggravated the disease of the skin. This much ascertained, 
the physician is ready to examine the affected surface for himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful infor- 
mation of which the patient is totally unconscious. Much of this is 
difficult to describe, as it is the rich fruit of wide experience and care- 
ful scrutiny. With a gentle, courteous, and sympathizing manner the 
diagnostician must combine the art of a detective and the skill of a 
swordsman. Glancing occasionally at the face of his patient while 



GENERAL I) LA GNOSIS. 79 

making record of the answers given, he will, of course, have observed 
any eruption upon that portion of the body. He will have made a 
mental note of the temperament of the sufferer, and of any movement 
made by the latter indicating a tendency to scratch or rub portions 
of the skin. He will have noticed the posture, clothing, and head- 
apparel ; the existence of hair on the scalp or extensive baldness ; 
the condition of the exposed hands as indicating manual labor or the 
reverse ; and, in the absence of facial lesions, will have observed the 
special tint of the skin of the face, as suggesting anaemia, chlorosis, or 
a general condition of cachexia. The facial expression, as indicative 
of anxiety or placidity, habits of debauch, sexual excesses, etc., will not 
have escaped his attention. All this and much more will possibly have 
enabled the questioner to direct his interrogatories into the channel in 
which they will elicit the most useful responses. The posture, cries, 
facial expression, and general condition of nutrition of the infant will 
have been no less carefully noted. 

Proceeding to the examination of the affected integument, the phy- 
sician must assure himself of a good light, as colors are best distin- 
guished by daylight and artificial illumination should be reserved for 
exploration of the cavities of the body. The air of the apartment 
should be sufficiently warm to permit of exposure of the person with- 
out discomfort and without causing disturbance of the cutaneous cir- 
culation. Adult males and children of both sexes should have the 
clothing completely removed so that all portions of the skin may be 
inspected. One portion of the body may, however, be examined, and 
then covered if desired, while the examiner proceeds to direct his 
attention to another part. In the case of women the investigations 
should be conducted with all the tact and delicacy to which the sex is 
entitled. 

The examination, whenever practicable, should extend over the entire 
surface of the integument. The importance of this point can scarcely 
be exaggerated. It must be remembered that the physician should be 
very much wiser than his patient, and the assurances of the latter are 
always to be accepted with reserve. Thus, one who merely exposes his 
leg, stating that this is the only part of his body affected, may have 
concealed beneath his clothing extensive varicosities of the veins of 
the thigh, a typical syphilitic exanthem over the belly, a significant 
scar on the elbow, an extensive patch of tinea versicolor on the surface 
of the chest, or a blennorrhagic discharge from the urethra, the medi- 
cation of which has induced the rash for which he seeks relief. These 
are not the rare, but are the common cases of a daily experience. 

Observation should be had at this time of the general and special 
features of the eruption. As to the former, the following considera- 
tions should be borne in mind : 

The original manifestations of a cutaneous disease may be masked 
or entirely hidden by the lesions resulting from scratching, or by a 
dermatitis due to local applications, or to drugs swallowed for the 
relief of the original disorder. It is of the greatest importance that 
the accidental nature of these symptoms be recognized, as they other- 
wise lead to great confusion in diagnosis, 



80 GENERAL DIAGNOSIS. 

Rarely a disease involves the entire surface of the body, leaving 
no part unaffected, and then is said to be universal in distribution ; 
more frequently an eruption affects at one time several or most of 
the regions of the body-surface, and then is called generalized ; much 
more commonly an eruption affects a considerable portion of but 
one or several regions, and is said to be diffuse ; or it is limited to 
small areas of one or several definite regions, and is known as a local 
eruption. 

A symmetrical eruption, one equally distributed over correspond- 
ing regions of both sides of the body, is rarely the result of an etio- 
logical factor operating upon the outer skin. It more often points to 
an efficient cause of internal origin. An eruption affecting the covered 
integument, never creeping out upon the exposed surfaces, suggests the 
operation of the clothing, as the latter may chance to prove the nidus 
or protector of a parasite, the fabric which has been colored by a noxi- 
ous dye, the recipient of a chemically altered secretion which has proved 
irritating to the surface, the instrument of friction, or the source of 
increased temperature at the surface by its non-conductivity of heat 
and unseasonable thickness. An eruption accompanied by excoriations 
and scratch-lines is usually severest in the parts most accessible to the 
hands, and least developed where the latter have the least play, as 
over some parts of the back. An eruption limited to the hands is 
likely to be one induced by an agent to which the hands alone have 
been exposed. Such are the eruptions originating in the trades and 
domestic occupations ; in the latter, an eruption more distinct on the 
right hand, and especially about the right thumb and index finger, tells 
its own story when the hand-worker is not ambidextrous nor left- 
handed. Artificially and intentionally produced eruptions, as in ma- 
lingering, hysteria, mental depravity, and insanity, usually occur also 
in parts to which the right hand finds easy access. 

Eruptions occurring on the face, the hands, and the genitalia of 
men, or on the face, hands, and mammae of women, point to external 
contact or contagion (poison-ivy, scabies, croton-oil, etc.), since, next 
to the face, the hands are more commonly brought in contact with the 
parts named in the sexes respectively, as the wearing-apparel of each 
suggests. 

An eruption limited to the forehead suggests an inspection of the 
hat-band, the veil, or the overlying false hair ; to the ears of women, 
a glimpse at possibly cheap ear-rings ; to the centre of the root of the 
neck, before or behind, a scrutiny of the collar-button and collar ; to 
the anus of the baby, an inquiry as to the changing of its napkins ; 
to the wrists of the adult, a question as to the cuffs worn ; to the feet, 
information respecting gaiters, varicose veins, recently cut corns, and 
ill-fitting boots. Eruptions springing from each of these causes have 
long and vainly been treated as " diseases of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetrically 
operating causes — that is, the accidents of environment, or else influ- 
ences exerted within the body unequally on its two lateral halves. 
Thus, an orthopaedic apparatus worn to correct talipes excites a der- 
matitis of the leg of the affected side only ; and zoster of the trunk is 



GENERAL DIAGNOSIS. 81 

evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphilides, 
the quinine-exanthem, rubeola, and even lupus erythematosus, are re- 
markable illustrations of this fact. 

Proceeding with the visible characteristics of the disorder, the phy- 
sician will not fail to note an acuteness or ehronicity of the eruption ; 
also, the presence or absence of an exudate on the surface. 

After obtaining an impression of the general features of an eruption 
the individual lesions should be carefully studied. The type of lesion 
(papule, tubercle, vesicle, etc.) should be noted. When the lesions are 
multiform the different types should be examined to determine, if pos- 
sible, which are primary and which consecutive in appearance, which are 
essential and which accidental in the process. For the purpose of 
studying the characteristics of the individual lesions, those of most 
recent appearance (usually at the border of a patch), and as yet un- 
modified by scratching, treatment, and other influences, should be 
selected. Often, however, the full evolution of a lesion requires time, 
and its successive stages should be determined by observing a number 
of lesions of different ages. 

The arrangement of lesions varies greatly in different diseases. 
When grouped such lesions may develop in circular, oval, angular, or 
irregular-shaped areas ; or in circinate, gyrate, serpiginous, straight, or 
irregular bands and lines. In some affections (as ringworm, psoriasis, 
syphilis) the areas may become clear in the centre as the border pro- 
gresses. Lesions may be grouped, and yet discrete in that each lesion 
preserves its outline and identity ; or they may coalesce so completely 
that all trace of the form of the individual lesion is lost. 

The definition of lesions is another important diagnostic feature in 
which cutaneous affections vary greatly : the line dividing the diseased 
from the normal skin may be so sharp and fine that it can be traced 
with the point of a pin ; or the lesion may shade so gradually into the 
normal skin that its outline cannot be definitely determined, and it is 
said to have poor definition or none. 

The color of lesions of the skin often depends greatly upon circum- 
stances having no bearing upon the disease in question. It thus varies 
with the natural color (light or dark) of the individual's skin, with the 
temperature of the surface, and with the amount of irritation to which 
the surface has been subjected by friction of rough clothing, scratching, 
treatment, etc. There are, however, some diseases (syphilis, lichen 
planus, tinea versicolor, favus, and others) in which the color may be 
of great importance in the diagnosis, and there are many maladies in 
which consideration of this characteristic of the eruption is of value 
if the accidental modifications be borne in mind. The acuteness or 
ehronicity of a disease is often indicated by the color of the lesions. 
The persistence, modification, or disappearance of color under pressure 
should be noted. For this purpose a small glass disc or glass tongue- 
depressor is better than the finger. 

In judging of the size of a lesion it is sometimes important to learn, 

6 



82 GENERAL DIAGNOSIS. 

by palpation, how much of it is above the general surface of the skin 
and how much is more deeply situated. In noting the shape of papules, 
tubercles, vesicles, and pustules, both apex and base should be taken 
into consideration. Thus, the apex may be pointed (acuminate), rounded 
(obtuse), flat (plane), or depressed (umbilicated). The base may be 
round, oval, angular, polygonal, or irregular. 

The situation of lesions in or about the hair-follicles or at the 
opening of the ducts of the sebaceous or coil-glands is a diagnostic 
point of great value. It is important to know if certain lesions 
appeared first on normal skin, or if they originated in other lesions. 
Thus, vesicles and pustules may arise from sound surfaces, or from the 
apices of papules or tubercles. The majority of even the elementary 
lesions are probably preceded by macules, which, however, are usually 
so transitory as to be unrecognized and unimportant. 

The career of an individual lesion, which often bears no relation to 
the duration of the disease as a whole, should be noted. Thus, the 
vesicle of eczema rarely exists as such for more than a few hours, 
though by the formation of new vesicles eczema may persist for months, 
while in zoster individual vesicles last several days, though the disease 
as a whole is short-lived. In some diseases the type of lesion remains 
the same throughout its career unless modified by treatment or external 
influences, while in others the type changes or is complicated by other 
types. Thus, the papule may be modified by developing at its apex a 
vesicle or pustule. The career of lesions can usually be studied, not 
only by watching them from day to day, but also — and more easily — 
by observing at one time a number of lesions in various stages of 
development. 

As the lesions of different affections vary greatly in their evolution 
and career, so do they in their involution. While in the majority of 
instances it is the recent and newly formed lesion that is most desira- 
ble for purposes of study, there is often much to be learned from the 
manner in which lesions disappear and in the traces they leave behind. 
The papule or tubercle which ulcerates usually suggests (aside from 
some rare diseases) syphilis, tuberculosis, or carcinoma, and may be 
sufficient to exclude from the diagnosis the possibility of psoriasis, 
seborrhoea, and other superficial affections. In a doubtful case the 
termination of some of the lesions in scar-tissue may be the one fact 
needed to make a differential diagnosis between seborrhoea and lupus 
erythematosus, or between a circinate form of psoriasis and a similar 
type of syphilitic eruption. Pigmentation sufficiently characteristic 
for a diagnosis is left after the otherwise complete involution of some 
lesions. This is most frequently true in zoster, lichen planus, and 
some forms of syphilitic eruptions. In estimating the time of involu- 
tion of lesions and in making a prognosis regarding the disappearance 
of pigmentation (a point upon which patients are often very solicitous) 
it should be remembered that pigment is usually removed very slowly 
from the lower extremities and other dependent portions of the body, 
and that in such localities it may persist for months or years after it 
has disappeared from parts in which the return-circulation is better. 

Certain lesions have special features that should be studied. These 



GENERAL DIAGNOSIS. 83 

are given in detail in the last division of the outline at the end of this 
chapter. 

Before concluding his examination the physician will rupture a 
bleb, pustule, or vesicle, should such be found, to discover the nature 
of its contents. He will remove one or several crusts in sight, to 
expose the surface on which they rest. He will scrape away a few 
scales with the dermal curette for a similar reason. He will pinch up 
between his thumb and finger a portion of each part, in order to deter- 
mine its infiltrated condition, its atrophy, or its attachment to the tissues 
beneath. He will pass his hands over the surface to recognize the firm- 
ness or the softness of the lesions, their inflammatory, hyperplastic, 
or neoplastic character, their dryness or moisture, and the existence of 
sebaceous or of perspiratory secretion. He will look at the mouths of 
the follicles where such secretion is retained or is abundantly exuded. 
He will discover any lice or their ova between or upon the hairs, any 
ascarides at play about the anus, any morbid formation of the nail or 
deformity of its matrix. He will examine for inguinal, post-cervical, 
axillary, and epitrochlear adenopathy, and will thus be often greatly 
aided in his task. This done, he will question in turn for himself, and 
by the methods recognized in medical science, the organs of the body 
other than the skin. He will inspect the tongue carefully, and if then 
he considers himself through with the mouth he will be guilty of 
great error. The gums rarely deceive the questioning eye; the inside 
of the lips, the fauces, and the tonsils are all to be searched. A 
mucous patch here will often echo the story of a palmar or a plantar 
sphiloderm. The laryngoscope may be called for in syphilis, cancer, 
lupus, and leprosy. The degree of distention of the belly and the 
region of hepatic dulness should not be overlooked. The genitalia of 
men, and of children and infants, can usually be explored. For 
women unaffected with syphilis or disease limited to these parts an 
exception in this particular should usually be made. 

In many cases the microscopical and bacteriological examination 
of hairs, scales, crusts, exudate, or tissue will aid greatly in the diag- 
nosis, and should not be neglected. In some instances such examina- 
tions are essential to the formation of a correct diagnosis. 

AVith the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
after the manner described above is in possession of the diagnosis for 
which he seeks. If the facts thus acquired have properly been re- 
corded, and yet do not spell out such a diagnosis to his eyes, they will 
probably be legible to others with a wider experience or riper judg- 
ment, to whom such a record may be shown. It is not claimed that 
this exhaustive method of examination is requisite in every case, as, 
for example, in order to recognize a favus or to differentiate erysipelas 
from erythema. But it is certain that few obscure cases of skin dis- 
ease will remain such under severe scrutiny, and the establishment of 
a thorough and exhaustive method of examination is important in the 
earliest experience with disease. Let the student or the practitioner 
conduct such an examination in the first few cases of eruption upon 
the surface of the body for which his advice is sought, and he will 



84 



GENERAL DIAGNOSIS. 



establish a habit of observation in comparison with which his pecuniary 
or professional success in the management of the same cases wdll in- 
deed be of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which is not 
based upon such an examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the verdict of even skilled 
practitioners may be founded upon an error. The careful diagnostician 
should begin his task in a spirit of skepticism, and pronounce definitely 
only upon ascertained facts. The man who says he has an " eczema " 
may be louse-bitten; the woman who has been "overheated" may 
prove syphilitic. The patient recognized as suffering from ringworm 
of the beard may not have been infected under the hands of a barber. 
Finally, the eruptions upon patients unmistakably syphilitic are often 
of other than syphilitic origin. These infected subjects — men, women, 
and children — are exposed daily to the accidents from which the non- 
infected suffer. They exhibit acne, physiological alopecia, and der- 
matitis medicamentosa equally with the non-syphilitic. 

The following outline for the methodical examination of a patient 
affected with skin-disease is based on the subjects considered in the 
preceding pages, and is given in such detail that a careful investigation 
of the questions suggested should furnish material for all but excep- 
tional cases. For the average case much may be omitted. 

The first attempts to follow such a scheme are necessarily tedious, and 
therefore often discouraging; but one patient thus carefully examined 
is of greater educational value than an aimless and indefinite examina- 
tion of a dozen cases. There is no greater economy of time than is 
found in methodical and systematic habits of work. 



HISTORY. 



I. Name and Kesidence. 
11= Age. 

III. Sex. 

IV. Married or Unmarried. 

1. Children. 

a. Living. 
6. Dead. 

2. Abortions or Miscarriages. 

Family History. 



V. 
VI. 

VII. 
VIII. 

IX. 



Individual History, including that 

of previous skin-diseases. 
Occupation. 
Habits, of eating, drinking, bathing, 

tobacco-usage, etc. 

Present State of Health. 
(Note the condition of the digestive, re- 



spiratory, circulatory, genito-urinary, 
and nervous systems ; also, defects in 
assimilation, elimination, and nutri- 
tion.) 

X. History of Present Skin-dis- 
eases. 

1. Cause— if known. 

2. Character at first. 

3. Sites affected in order. 

4. Manner of progressing. 

a. Slow or rapid. 

b. Steady or irregular. 

c. With exacerbations and remis- 
sions. 

d. With periods of entire freedom 
from symptoms. 

5. Changes in character. 

6. Subjective sensations. 

7. Duration. 

8. Effect of temperature and seasons. 

9. Treatment to date. 



OBJECTIVE SYMPTOMS. 



A. Accidental Complications due to \ C. Symmetry, or asymmetry. 



scratching, treatment, etc. 



Site. 

1. Universal. 

2. Generalized. 

3. Diffuse. 

4. Local. (Note influence of clothing, occu- 

pation, etc., 



D. Acuteness, or chronicity. 

E. Moisture, or absence of. 

F. Individual Lesions. 

1. Elementary (macule, papule, wheal, tuber- 

cle, tiimor, vesicle, pvstule, or bleb). 

2. Consecutive (scale, crust, excoriation, fis- 

sure, ulcer, or scar). 



GENERAL DIAGNOSIS. 



85 



I. Uniformity, or multiformity. 

II. Arrangement. 

1. Isolated 

2. Grouped. (Circ incite, linear, etc.) 

3. Discrete. 

4. Coalescing. 

5. Irregular. 

III. Definition. (Sharpj'air, poor, or none.) 

IV. Elevation, or depression. 

V. Color. 

1. Persistent. 

2. Changing or disappearing under 

pressure. 

VI. Shape. 

1. Apex. 

2. Base. 

VII. Size. 

1. Superficial. 

2. Deep. 

VIII. Anatomical site. 



IX. Consistence. 

1. Firm. 

2. Soft. 

X. Base. 

1. Color. 

2. Infiltration. 

XI. Evolution. 

1. From sound skin. 

2. From other lesions. 

XII. Career. 

1. Transitory. 

2. Persistent. 

3. Type. 

a. Simple. 

b. Changing, 

c. Modified. 

XIII. Involution. 

1. Resorption. 

2. Exfoliation. 

3. Ulceration. 

4. Atrophy, etc. 

XIV. Sequelse. 

1. Stains. 

2. Scars. 



SPECIAL FEATURES TO BE OBSERVED IN CERTAIN LESIONS. 



A. Vesicles, Pustules, or Blebs. 

I. Roof. 

1. Tense. 

2. Flaccid. 

3. Easily ruptured. 

II. Contents. 

1. Translucent, or opaque. 

2. Serous. 

3. Purulent. 

4. Hemorrhagic. 

III. Surface beneath. 

IV. Areola. 

V. Involution. 

1. Desiccation. 

2. Rupture. 

3. Crusts. 

B. Scales. 

I. Size. 
II. Color. 

III. Quantity. 

IV. Consistence. 

1. Dry. 

2. Fattv. 

3. Friable. 

4. Tough. 

V. Attachment. 

1. Firm. 

2. Slight. 

VI. Surface beneath. 

1. Color. 

2. Dry. 

3. Greasy. 

4. Hemorrhagic. 

C. Crusts. 

I. Size. 
II. Shape. 

III. Color. 

IV. Composition. 

1. Serum. 

2. Pus. 

3. Blood. 

V. Attachment. 

VI. Thickness. 



VII. Consistence. 
VIII. Surface beneath. 

D. Excoriations. 

I. Distribution. 
II. Shape. 

III. Arrangement. 

IV. Relation to other lesions. 
V. Exudation. 

E. Fissures. 

I. Distribution. 

II. Size. 

1. Length. 

2. Depth. 

ni. Pain. - 
IV. Moisture. 

F. Ulcers. 

I. Size. 
II. Shape. 

III. Depth. 

IV. Base. 

1. Soft. 

2. Infiltrated. 

3. Indurated. 

V. Edges. 

1. Sloping. 

2. Perpendicular. 

3. Punched. 

4. Ragged. 

5. Everted. 

6. Undermined. 

7. Soft. 

8. Indurated. 

VI. Floor. 

1. Smooth. 

2. Uneven. 

3. Clean. 

4. Pus-covered. 

5. Granular, 
ft. Sloughing. 

7. Hemorrhagic. 

8. Glazed. 



86 



GENERAL DIAGNOSIS. 



VII. Secretion. 

1. Scanty. 

2. Profuse. 

3. Serous. 

4. Purulent. 

5. Hemorrhagic. 

6. Odor. 

VIII. Pain. 
IX. Crust. 
X. Evolution. 
XI. Duration. 

XII. Involution. 

(Note carefully the number and location 
of ulcers, the age of the patient, and the 
character of scars if present.) 

Go Scars. 

I. Size. 



II. Shape. 

III. Color. 

IV. Depression, or elevation. 

V. Texture. 

1. Soft, pliable. 

2. Hard, indurated. 

3. Thin. 

4. Thick. 

5. Smooth. 

6. Rough, corded. 

VI. Attachment. 
VII. Deformity. 
VIII. Subjective sensation. 
IX. Absence or presence of hairs, glands, 
and papillae. 



VI. GENERAL PROGNOSIS. 



The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin-diseases. 
Many of the latter are trivial, some are grave, a few are inevitably 
fatal in their termination. Thus, general exfoliative dermatitis, lep- 
rosy, sarcoma, carcinoma, at times lichen ruber, and variola in the 
unprotected are of grave portent ; while the ordinary congestions and 
exudations, the great majority of all cases of acquired syphilis in 
adults, and the entirely curable diseases induced by parasites do not 
excite alarm in the breast of the average patient with respect to his 
longevity. 

The questions, however, as to his future, which are urgently pressed 
by the victim of cutaneous disease, are both numerous and important. 
He is anxious as to the time during which he must suffer ; as to the 
possibility of conveying the disease to his progeny or other members 
of his family ; as to the disfigurement of his person that may result ; 
as to the scars which he may carry for the remainder of his life ; as 
to the possible recurrences of his malady in the future. The responses 
to these questions will largely be influenced by the prognosis of the 
physician. 

Some diseases of the skin are acute, pursue a rapid course, and 
are prompt to disappear. Others are chronic, rebellious to treat- 
ment of the most energetic and skilful character. Others, again, 
though not shortening life, are never relieved while life is continued. 
Some disappear only to reappear at more or less regular intervals. 
There are cutaneous diseases which affect one individual but once in 
his lifetime ; others which reappear at the instant the patient is again 
exposed to their exciting cause. There are cutaneous diseases so dis- 
torting and destructive in their effects that their victims have com- 
mitted suicide under the influence of the morbid emotions which they 
have as a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its exciting cause, and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne ; and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the other ; thus, there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated with 



88 GENERAL PROGNOSIS. 

albuminuria ; and the eczema of an infant starving for want of breast- 
milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prognosis 
of the disease of the latter will largely depend the professional success 
of the physician. Scrupulous honesty should here be welded with all 
the skill that science can command. That a disease does not endanger 
life is not an argument in favor of its amenability to treatment. The 
practitioner should never smTer himself to be pushed by his patient to 
the position that an obstinate disease is readily manageable. It is the 
height of folly to estimate lightly that zoster of the forehead, the scars 
of which the patient may exhibit to all who afterward look upon his 
face both in life and in death. He who engages to relieve an alopecia 
areata in the month may have a year in which to repent his precipi- 
tancy. There is no way in which the conscientious physician can so 
readily secure the confidence of his patient, and with it that will- 
ingness to submit to appropriate treatment which is begotten of such 
confidence, as by demonstrating his ability to forecast the future of a 
disease ; in other words, to describe accurately its prognosis. 



VII. GENERAL THERAPEUTICS. 



A consideration of the subject of the methods of treating skin- 
diseases in general suggests at once the intimate relation which subsists 
between the integument and other organs of the body. The etiology 
of one largely explains the causes of the disease in all. The patholog- 
ical processes in each are subordinated to the same general laws. The 
principles of treatment are very similar in all the disorders of the 
body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; secondly, where relief is impossible, such manage- 
ment of the morbid process as will mitigate its severity and render the 
victim of the disease more comfortable. A higher and more scientific 
achievement than either is the prophylaxis by which man is enabled to 
escape the disease altogether. He can by his wisdom largely diminish 
the danger to which his integument is exposed; he can, to a certain 
extent, shelter himself from extremes of temperature, traumatism, toxic 
agents, and contagious diseases ; he can, by observing the simple rules 
of hygiene, fortify his skin against the lesser evils which may befall 
it. Here, however, the subject under consideration involves disease 
which is actually present and in progress. 

The management of diseases of the skin demands of the practitioner 
a sound knowledge of general medicine and an experience in disorders 
other than those of the integument. Dermatology is a branch of gen- 
eral medicine, and he who would succeed in the one department must at 
least be at home in the other. He who cannot succeed in the one 
field will almost surely fail to secure the best results in the other. 
Much indeed of the management of diseases of the skin can be cor- 
rectly described as the pure practice of medicine. Many of the 
methods, most of the means of diagnosis, much of the pharmaceutical 
aid utilized by the general practitioner, are indispensable in the field of 
dermatology. 

It is scarcely needful to set it down at this date that the old doctrines 
respecting both the danger of " driving in" certain diseases of the skin, 
and of the importance of "driving out" others, are relics of a super- 
stitious ignorance. There is no disease of the skin the continuance of 
which offers a bar to other disorders or furnishes a guarantee of the 
future health of the patient. There is no disease of the skin which 
does not call for relief as promptly as the requirements and safeguards 
of science will permit. The retrocession of the exanthematous symp- 
toms of a systemic poison are not of the class of involution of lesions 
to which attention is here directed. 

In beginning the treatment of disorders of the skin it is scarcely 

89 



90 GENERAL THERAPEUTICS. 

necessary to repeat that the diagnosis should be established by the 
methods already detailed ; and that in attempting to adjust remedies to 
the morbid state due attention must be given to the past history of the 
complaint, to its remote or immediate causes, to its duration, to the 
nature of the disease (whether the latter has changed in type or severity 
since the beginning), and in particular to the special features presented 
at the moment of instituting treatment. The matter of diet is one with 
respect to which experts are not as yet upon all points agreed. In 
general it may be said that in all inflammatory affections the diet 
should include food which is simple, digestible, and free from excess of 
nitrogenous and hydrocarbonaceous principles. The diet appropriate 
for the gouty state in the majority of gouty patients suffering from 
dermatoses must be rigidly enforced, even admitting that too severe a 
regimen is to be deprecated for the gouty when not actually suffering 
from a crisis of the disease. In all attacks of urticaria the food per- 
mitted should be made to correspond carefully with the list of articles 
known to be incapable of aggravating the disorder, and too much im- 
portance cannot be attributed to the regulation of the food of infants and 
children affected especially with eczema. In glycosuric xanthoma, in 
the pruritus of albuminuria, in the tuberculoses of the skin, in acne 
cachecticorum, and in other disorders the selection of a dietary appro- 
priate to the systemic state is of vital importance. On the other hand, 
it is to be conceded that in some cutaneous maladies, such as vitiligo, 
the disorders due to vegetable and animal parasites, in molluscum, and 
in other affections which might be named, the subject of dietetics is 
without importance. 

Like all other diseases of the body, those of the skin may be divided 
into three classes with relatively fixed limits. 

The first class embraces all the diseases which have a natural tendency 
to pursue their course to a favorable termination. It includes all those 
affections which, either mild or severe, require absolutely no treatment 
of an active character. It is the duty of the skilful physician to watch 
the evolution of these maladies, and to discharge a most important part 
by refraining from all therapeutic measures which in such cases might 
prove hurtful. By his judicious counsel, also, he hinders patients and 
their friends from pursuing a course which might prove prejudicial to 
the disease. 

The second class embraces all those skin-affections which are either 
inevitably fatal or hopelessly remediless while life is prolonged. For- 
tunately, this includes but a small proportion of the large list. Here 
the duty of the physician is plain. He should assuage pain, attempt to 
relieve deformity, administer to the comfort of the afflicted in other 
ways, and by his patient courage inspire confidence and hope. It 
must not be forgotten that the skill of man has not yet reached the 
acme of human need. In the presence of many diseases of the body 
he stands absolutely helpless, and the speediest way to success in such 
cases is to begin by an honest admission of the plain fact. 

The third class of affections naturally embraces all not included in 
the first two classes. Here disease may be prolonged or be shortened 
in its course, rendered acute or chronic, made more or less endurable, 



INTERNAL TREATMENT. 91 

permitted to become inveterate, or absolutely be relieved by prompt 
and energetic measures, according as it is, or is not, judiciously and 
skilfully managed. Here are gained the most brilliant successes of 
the dermatologist ; here also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment the 
question naturally arises as to whether this treatment shall be internal — 
that is, by medicaments ingested j or external — that is, by local thera- 
peusis ; or by combination of the two methods at the same time. 

INTERNAL TREATMENT. 

With regard to the question of internal treatment, which is one 
of pressing importance, it can safely be said that there are no remedies 
to be given by the mouth that can be described as certainly and spe- 
cifically curative of the diseases of the skin. The number of medicinal 
agents employed with this end in view is incredibly large, by far the 
greater part being obtained from the vegetable kingdom. With few 
exceptions, some of which are enumerated below, the most esteemed 
of these agents exert only an indirect therapeutic effect upon the in- 
tegument. The larger number of medicaments thus used are, it must 
be admitted, without value of any kind, but will probably continue to 
be vaunted as possessing specific virtue so long as credulity on the one 
hand, and avarice on the other hand, move the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as valu- 
able, when ingested, for the relief of cutaneous disorders. It is known 
to exert its effects almost exclusively upon the epithelia of the skin, 
and upon these, so far as therapeutic effects are concerned, only when 
they are the seat of subacute and chronic exudation. Upon the acutely 
inflamed epidermis the action of arsenic is unfavorable. If given for 
long periods of time, it may produce a generalized pigmentation and, 
occasionally, a generalized hyperkeratosis of the skin. It frequently 
produces excessive keratosis of the palms and soles, which in special 
cases has terminated in cancer of the skin. Operating favorably in 
this limited class of cases, it also operates slowly, requiring months 
for the production of its curative effects. Its administration is attended 
at all times with the hazard of producing toxic effects, which, how- 
ever, when the result of the exhibition of the drug in medicinal doses, 
are limited usually to a mild exanthem upon the skin, moderate coryza, 
and some redness from congestion of the vessels in the eyes and eyelids. 

Arsenic is used chiefly in psoriasis, acne, squamous eczema, 
pemphigus, and lichen ruber, its doses in cases of children being 
relatively large. It should be administered only after eating, and a 
minimum dose first be employed in order to test the susceptibility 
of the patient to its action. It should be remembered that the 
toxic effect of this, as also of several of the other drugs mentioned 
below, is often speedily noticed after the first exhibition of a relatively 
small dose. Toleration once established, the dosage may be cautiously 
increased. 

The forms in which arsenic is usually administered are : the prepa- 
rations of arsenious acid, such as the popular tablet-triturates made 
up in different and most commonly administered doses ; the liquor po- 



92 GENERAL THERAPEUTICS, 

tassii arsenitis (Fowler's solution) ; the liquor arsenici et hydrargyri 
iodidi (Donovan's solution) ; the liquor arsenici chloridi (de Valan- 
gin's solution) ; and the Asiatic pill. Duhring's modification of this 
pill is obtained by making 2 grains (0.13) of arsenious acid, and 32 
grains (2.2) each of black pepper and licorice powder into thirty-two 
pills by the aid of a sufficient quantity of gum Arabic and water. 
Arsenic is also at times advantageously combined with other indicated 
medicinal substances, such as iron and potassium iodide. 

An unprejudiced view of the value of arsenic, even in cases prop- 
erly selected for its internal administration, justifies the conclusion that 
it is in diseases of the skin a remedy of uncertain effect, and in that 
proportion disappointing. After collation of the experience of ex- 
perts it has been shown that the common practice of giving arsenic in 
many cutaneous diseases is both harmful and irrational, not merely 
because of its effect in inducing cutaneous congestion and pruritus, 
but also because of the reliance placed upon it to the exclusion of 
other and better methods of treatment ; and that the beneficial effects 
supposed to follow its administration are often due to other causes. 
No series of carefully recorded cases has ever been published in which 
notable therapeutical results have been shown to result solely from its 
administration. Even in pemphigus, psoriasis, chronic eczema, and 
lichen ruber, in which arsenic has been thought to possess special 
efficacy, it has in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of 
the earliest, should be one of the last remedies to be selected in the 
management of cutaneous diseases by the general practitioner ; secondly, 
that, when thus selected, its value will probably prove greatest if the 
eruptive lesions be seated superficially, be generalized, diffused, or in 
evident association with neurotic symptoms ; thirdly, that in any case its 
failure to relieve should not be regarded as definite, if only Fowler's 
solution has been administered. 

Mercury is a remedy of great value in cutaneous as in other affec- 
tions. Its specific action upon the liver and intestinal secretions calls 
for its employment in many cases in which intestinal elimination is 
deficient, in which there is habitual constipation, and in which there is a 
decided tendency to congestion of the blood-vessels of the head, of the 
anogenital region, and even of the lower extremities. In all of the 
distinctly gouty dermatoses, in all eczemas of the florid-faced type of 
patients, in many cases of intense pruritus resulting from toxic influ- 
ences, and in almost all the eczemas of infancy and childhood, calomel, 
blue pill, and the gray powder are well nigh indispensable in securing 
the speediest and happiest results. Indeed, there are few adult patients 
seeking relief from a simple inflammatory affection of the skin and 
having at the same time a coated tongue, an offensive breath, and a 
loaded colon, who will not be benefited at the outset of treatment 
by free catharsis under the influence of a mercurial. In many cases 
indeed of aggravated types of engorgement of the skin, localized or 
generalized, a dose of blue mass may be given at night, on successive 
nights, or for a fortnight or more, and followed by a saline laxative in 
the morning, with the best effect upon the exanthem present. 



INTERNAL TREATMENT. 93 

Mercury in the treatment of syphilodermata is of incontestable value, 
and its injudicious employment in many cases springs from that pre- 
cise fact. The vulgar prejudice that many disorders of the skin, really 
not syphilitic, are obscure manifestations of lues in a preceding genera- 
tion and amenable to mercurial treatment, is a striking illustration of 
the necessity of accurate diagnosis in cutaneous diseases. When 
syphilodermata are present corrosive sublimate is often superseded, in 
consequence of its irritative effects, by the compounds of the metal 
with iodine. The gray powder is useful chiefly in case of infants and 
children, though its not infrequent development of the corrosive chlo- 
ride has limited its employment. Calomel and the mercurial pill should 
be employed only for transient effect, as when administered for long 
periods they are much more than the other preparations mentioned 
likely to produce ptyalism. 

Iodine and its compounds are also chiefly used in syphilitic disorders 
of the skin, but they possess a wider range of value than the mercurials 
in the treatment of other cutaneous affections. Here, too, the abuse of 
the drug furnishes a long list of cutaneous disorders either originated 
or aggravated by its employment. As in the use of arsenic, toleration 
should be established before large doses are exhibited. The compounds 
chiefly used are the iodides of potassium, sodium, lithium, and ammo- 
nium ; iodo-nuclein, iodipin and iodoform. Iodine has been admin- 
istered for the relief of the scrofulodermata, lupus, keloid, psoriasis, 
and syphilitic affections of the skin. As to the latter, it may be added 
that in the earlier symptoms of lues it is often a source of positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the skin, 
and was for that reason held in high favor by the distinguished Hebra, 
though its action is almost exclusively that of a nutrient of the general 
system. It is employed chiefly for its roborant effects, which are 
similar to those of the digestible aliments. Its special value in the 
treatment of infants and children affected with cutaneous diseases can- 
not be questioned. It is, moreover, of great use in maturer years, and 
is advantageously exhibited in eczema, lupus, scrofula, syphilis, scle- 
roderma, and in all disorders of the integument accompanied by 
wasting. 

Cathartics, Alkalies, and Diuretics have an important place in 
the list of remedies valuable in the management of skin-affections. 
Cathartics are chiefly valuable in eliminating effete or toxic products, 
but they are effective also in reducing congestion of the body-surface. 
The value of mercurials in this connection has been already suggested. 
The saline laxatives and cathartics also are of great service, especially 
the magnesic and sodic sulphates, and the Rochelle, Carlsprudel, and 
Hunyadi Janos salts. The useful and frequently ordered mistura 
ferri acida is compounded as follows : 



R Magnes. sulphat., ;|jss ; 45 

Acid, sulph. arom. (vel dilut.), 3j ; 4 
Ferri sulphat., gr. viij ; 

Aq. menth. piper., ad ^iv ; 120 



50 

M. (filtra). 



Sig. A tablespoonful in hot or cold water before breakfast daily. 



94 GENERAL THERAPEUTICS. 

The alkalies are extremely useful in all cases of gouty disorder, and 
in erythema, acne, and certain forms of eczema. The carbonates of 
sodium, potassium, and lithium are chiefly employed, as well as the 
liquor potassse. The prevalent misconception of the value of lithium 
carbonate and other salts of the same base has produced a reaction 
which suggests a preference of one of the other alkalies when such are 
indicated. Diuretics, with the exception of water, are less valuable in 
cutaneous than in other affections, but they yet are administered often 
with special advantage in inflammatory disorders. 

Water when drunk in sufficient quantities and at proper times is 
of great value as a diuretic and as an aid to elimination. Soft water 
is to be preferred, and should be drunk freely at all times except dur- 
ing meals and for an hour after eating. The best results are obtained 
by drinking a given amount (four to eight, or more, ounces) every hour. 
As such a course is usually impracticable outside of hospitals and 
health-resorts, under ordinary circumstances two or three glasses may 
be ordered to be taken on rising in the morning and before meals. 
The free use of water, especially if iced, with meals is a fruitful source 
of indigestion as a consequence of the chilling and large dilution of the 
stomach-contents. The vicious habits of rapid eating and imperfect 
mastication of food may often be corrected by simply abstaining from 
the drinking of liquids during the taking of food. 

Quinine, administered both as a tonic and an autiperiodic, is largely 
employed in cutaneous medicine for its generally recognized systemic 
effects. It produces, in susceptible individuals, a peculiar smoothness 
and softness of the skin, which usually disappear when the drug is 
suspended. Like arsenic and iodine, it is occasionally the cause of a 
generalized exanthem, and is capable of producing other toxic effects, 
such as failure of the heart's action, dizziness, and tinnitus aurium, 
symptoms recognized under the designation of cinchonism. It will, of 
course, exhibit its happiest effects in malarial affections with coincidence 
of cutaneous symptoms in the form of disease of the skin associated 
with a neurosis. 

Salol is a remedy of special value in many cutaneous disorders asso- 
ciated with intestinal sepsis. It is particularly useful in the forms of 
pustular acne when the subject of the affection has an habitually coated 
tongue, a foul breath, and defective digestion. 

Ergot and Ergotine, whether by exerting an effect upon the muscle- 
bundles or the vessels of the derma, or upon the uterus, or yet by its 
influence upon the general economy, is thought to possess some value 
in the treatment of several cutaneous diseases occurring in both sexes. 
Such are acne, purpura, and a few other disorders. 

Calx Sulphurata was once regarded as the most efficient of the 
sulphur compounds for internal use in cutaneous diseases. Its sup- 
posed value in furunculosis has led to its employment also in eczema, 
acne, and impetigo. It is given in doses of from y 1 ^ (0.004) to T 
(0.016) of a grain, three or four times daily. It is, however, a remedy 
uncertain in operation and of dubious effect. 

Chrysarobin has been administered internally by Stocquart 1 and 
1 Annates, 1884, s. ii., v., p. 15. 






INTERNAL TREATMENT. 95 

others, in closes of \ (0.01) of a grain, for a number of cutaneous 
disorders. 

Ichthyol, mentioned later as of some value when externally em- 
ployed, has also been given by the mouth. 

Jaborandi and Pilocarpine, probably as a result of the free dia- 
phoresis which they excite, unquestionably exert immediate thera- 
peutic effects in a number of cutaneous disorders. 

Sulphur, highly esteemed as a popular remedy in cutaneous affec- 
tions, exerts but little influence upon the latter when it is ingested. 
Its cathartic effect is the chief reason for its administration. It is 
recommended by Crocker in some of the disorders of the sweat-function. 

Antimony in small doses is of unquestioned value in many diseases 
of the skin. It is, when not contrainclicated, employed with advantage 
in psoriasis, pruritus, and some of the obstinate forms of eczema. 

Tar, Carbolic Acid, Creosote, Guaiacol, Resorcin, Turpentine, 
Copaiba, and Phosphorus are remedies which have been employed 
internally with appreciable effect in certain cutaneous maladies. They 
have been used with advantage in cases of lupus, eczema, psoriasis, 
and pruritus ; but the disagreeable effect of their internal administra- 
tion has been to a great degree a bar to their general employment. 
The " perles " of phosphorus and the elixirs of the same drug obviate 
this difficulty in the instance of at least one of these articles. Creosote 
carbonate given in capsules is usually well tolerated. 

Animal Extracts, Thyroid Extract, and other preparations of the 
thyroid, adrenal, and other glands of the larger mammals, have in recent 
years been employed largely in various diseases of the skin. In myx- 
eedema decided and brilliant results have been obtained, and the same 
is true of ichthyosis, psoriasis, and some tuberculous affections of the 
skin. The depressing action of thyroid-extract on the heart makes it 
an unsafe remedy to use except with caution. 

Maltine, and other preparations of malt alone or in the valuable 
combinations now on sale, are of marked value in promoting the nutri- 
tion of the skin. They are especially indicated where there is imper- 
fect digestion of the carbohydrates, and where fats are not readily 
assimilated. They are useful in acne, in scleroderma, in syphilis, in 
tuberculosis of the skin, and in many of the cachexias accompanied 
by cutaneous symptoms. 

Iron and its several compounds are invaluable in the management 
of a long list of cutaneous disorders. Iron is indicated in many cases 
of cachexia and struma ; in tuberculosis of the skin ; in syphilis ; in all 
the anaemias ; and in many cases of purpura and pemphigus. Fortu- 
nately, iron is often well assimilated when compounded with other drugs, 
and hence has been suggested the long list of compounds of iron and 
mercury and of iron and iodine in syphilis; of iron and quinine and of 
iron and the vegetable bitters in anorexia and anaemia ; and of iron with 
cathartics in atonic constipation. 

The Analgesics have occupied a small space in cutaneous medicine, 
and that space should be -more and more restricted. The use of acetan- 
ilid, of opium and its alkaloids, of phenacetine, of potassic bromide, 
of trional, of sulphonal, and of articles of the same class, has been 



96 GENERAL THERAPEUTICS. 

indicated for relief of the tormenting pruritus, pain, and insomnia 
accompanying a long list of dermatoses. Unfortunately, most of the 
preparations devised to insure relief, after a temporary calmative effect 
have a decidedly aggravating influence upon the exanthem present. 
To a degree scarcely noticeable in other cases have drug-habits been 
formed in consequence of the temporary assuagement of the local dis- 
tress when under the influence of an analgesic. As a rule, the most 
competent physician is he who secures relief for his patient without 
narcotizing the nerves which are uttering their protest by abnormal 
sensation. The expert reserves for the last extremity an ordering of 
medicines of the anodyne class in attempting to secure relief. 

Hypodermatic and Intracutaneous Injections of alcohol, arsenic, 
mercury, cocaine, carbolic acid, the alkaloids of opium, antitoxins, 
exalgine, of erysipelas-toxins, and other substances have been largely 
employed in the management of cutaneous disorders, some with 
marked success, others with doubtful results. The most brilliant of 
the achievements in this direction are without question the relief of 
the syphilodermata by deep intramuscular injections of mercury. The 
injection of the antitoxins which have been such a boon in an important 
group of general disorders has, on the whole, proved disappointing in 
cutaneous medicine. Attention has been directed to the special objec- 
tions in most of the affections of the skin to the use of anodynes and 
opiated medicaments by whatever route introduced into the system. 
The temporary alleviation, when secured, is gained at too great a cost. 

Tuberculin (Koch's lymph), Thiosinamine, Taurine, and yet 
other substances have been injected subcutaneously in the management 
of lupus, acne, eczema, psoriasis, lepra, and other affections. They 
have not as yet such an acceptance at the hands of the profession as 
would justify their employment in any save specially selected cases. 

Spraying the skin for antiseptic purposes is of value, and may be 
often employed with marked advantage. The several solutions of for- 
malin are best suited to the purpose. Frigorific sprays for the purpose 
of freezing a part of the skin selected for operation, as in the case of 
epithelioma, are indispensable to the operator. Those chiefly employed 
are discharged from bulbs containing ethyl chloride. 

Natural Mineral Waters. — The chief value of many of the mineral 
springs and health-resorts of the United States lies in the change of 
the manner of living that they invite and necessitate. Sunshine, pure 
air, recreation after the care and toil of business, change of climate, of 
foods and drinks, and even of cooks, often decide the question of 
speedy recovery. Unfortunately, both in America and in Europe, 
many of the health-resorts are peopled by unscrupulous charlatans, 
with a tendency to attribute all the benefits to be derived from these 
sources to the medicinal virtues of this or that particular spring, aided 
always by treatment according to their own peculiar methods. Many 
patients affected with disease of the skin are thus made worse by a 
temporary residence at noted health-resorts, and, therefore, it is often the 
case that a visit to the seashore, to the mountains, or to any healthful 
place in the country proves conducive to greater practical results. 
None the less the springs of America and Europe having mineral con- 






EXTERNAL TREATMENT. 97 

stituents, in many instances supply a valuable means of treating cuta- 
neous diseases. The sulphur waters of Richfield Springs, of Sharon 
Springs, and of Avon Springs, in this country, as of those of Europe, 
operate chiefly by an influence exerted upon the digestive tract ; the 
springs of West Virginia are examples of calcic waters having for the 
most part a diuretic effect. The fine water of the Poland Spring in 
Maine is chiefly valuable by reason of its remarkable purity. The 
alkaline waters of Colorado Springs, of Saratoga, and of other sources 
in America are rapidly securing a reputation equal to that of the 
famous Vichy, Carlsbad, and Ems of Europe. 

The chemical laboratories, however, are fast placing at the disposal 
of the consumer the salts, either natural or artificially produced, which 
represent the constituents of most of the waters highly esteemed, both 
here and abroad, in the management of disease. In this way the 
Apenta, Hunyadi Janos, Hathorn, Kissengen, Congress, Friedrich- 
shall, Rakoczy, and other waters may be produced at will by solution 
of the proper salts in water : and the latter in many of our large cities 
is now furnished after distillation and aeration in such purity that it 
competes with distilled water in the laboratory of the chemist and in 
the operations of the photographer. 

Of the chalybeate and arsenical waters, the former abundant in 
Michigan and New York, the latter best represented by that of Levico, 
in the Austrian Tyrol, it may be said that their use is often followed 
by excellent results, especially when the drinking of the water is as- 
sociated with the tonic regimen and healthful environment of the 
springs from which these waters are obtained. 

EXTERNAL TREATMENT. 

In the external treatment of diseases of the skin the indications are 
to hasten repair when this is possible ; to alleviate distress if palliatives 
only are admissible ; to destroy absolutely or excise the diseased tissue 
when this is justifiable. The following are the principal substances 
employed as external applications : 

Water, either pure or medicated by holding substances in solution 
or mechanical suspension, is applied either in baths or as lotions. 
Baths, local or general, may be employed for days continuously or but 
for a few moments at a time. They are given with water varying in 
temperature — cold, warm, or hot. Rain-water is to be used when 
practicable. 

Cold baths of short duration are generally followed by a sharp re- 
action, the skin becoming congested after the normal temperature of 
the surface is regained. It is for this reason that cold sponging of the 
inflamed skin is usually grateful so long as it is continued, and is suc- 
ceeded by an aggravation of the symptoms which it was intended to 
relieve. Continued applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation of the 
integument, while tepid water-baths are chiefly macerative of the sur- 
face. Hot baths are valuable in several of the exudative and hyper- 

7 



98 GENERAL THERAPEUTICS. 

trophic affections of the skin. The application of watery lotions to the 
broken surface of the skin is likely to be followed by endosmosis, 
unless the specific gravity of the serum of the blood and that of the 
fluid of the bath or the lotion are nearly the same. This imbibition 
of fluids by the broken skin is accompanied by slight swelling of the 
tissues and is productive of disagreeable sensations. 

The continuous warm water-bath in which the patient is immersed 
either for the greater part of a day or for a few hours at a time is an 
exceedingly valuable means of treating pemphigus, the severe grades 
of burns, and ulcerative affections of the skin. 

The most perfect of all applications of water to the surface of the 
body is that most resembling the water-bath in which the tender 
skin of the foetus is immersed for consecutive months. Here the 
bath is continuous ; the temperature is that of the viscera of the 
living animal ; and the delicate skin of the unborn child is anointed 
with a fatty substance which interferes with the macerative action of 
the surrounding fluid so long as the vitality is preserved at the average 
standard. The comfort and therapeutic value of a bath prepared and 
administered in approximation to this ideal can scarcely be overesti- 
mated. Were it not for the difficulties with which it is attended, so 
far as relates to many portions of the surface of the body, it would 
be possible with this single therapeutic measure to rob the exudative 
affections of the skin of many of their formidable features. 

Vapor, steam, Russian, and Turkish baths are less valuable than is 
usually supposed in diseases of the skin. The macerative effect they 
produce is not always desirable. They possess some value in severe 
general pruritus, in ichthyosis, and in keratosis pilaris. 

In acute inflammations of the skin the application of pure water, 
even when of proper temperature, is often prejudicial to the integu- 
ment, and soap-and-water washings may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients as 
to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by the 
addition of a large number of substances, such as marine salt, boric 
acid, corrosive sublimate, sodic and potassic salts, alum, tannin, the 
mineral acids, gum Arabic, gelatin, and bran. 

The alkaline bath, made by adding sodium bicarbonate or biborate 
to water having the proper temperature in the proportion of 12 ounces 
of either salt to 30 gallons, is usually grateful to the inflamed skin. 
Sulphur-baths are best prepared by adding an ounce of Vleininckx's 
solution 1 to the above-mentioned quantity of water. 

The natural Sulphur-baths of Richfield Springs and Avon Springs, 
in this country, are efficacious in certain cutaneous affections accom- 
panied by roughness and thickening of the integument. 



M. 



1 The formula is : 






R Calcis, 


Iss; 


16 


Sulphur, sublim., 


Sj ; 


32 


Aq. desk, 


3*; 


320 


Coque ad ^vj [200] deinde filtra. 






Sig. " Vleminckx's Solution." 







EXTERNAL TREATMENT. 99 

Tar-baths are usually given by first anointing the skin of the patient 
with the tarry substance to be employed, and by immersing the body 
in warm water for some hours afterward. The resulting effect can 
usually be accomplished as well by other measures. 

Salt- and Marine Baths possess the highest value with respect to 
the general health of the individual ; and are advantageously employed 
over the body-surface when, for example, the head alone is affected 
with a dermatosis (rosacea, acne, erythema), and when the salt is not 
brought into contact with the morbid surface. In very many cases 
a sea- or salt-bath produces aggravation of a cutaneous affection, and 
indeed, in some cases, is capable of begetting the same. A properly 
directed salt-bath or lotion, however, is at times positively beneficial, 
not merely in chronic, but also in acute affections of the skin. 

The strength of the usual marine salt-bath is \ pound to the gallon, 
though 10 pounds of the salt are often added to 25 gallons of water 
with advantage. The sea-salt is not preferable to the article obtained 
from the natural brine-wells of the interior of the country. For 
invalids the skin of the body may first be well rubbed with the finest 
table-salt well warmed in an oven, after which a tepid or warm bath 
may be used to cleanse the surface. 

Antiseptic Baths are most often employed by the surgeon. In the 
management of skin-affections local baths of boric acid in hot or cold 
water may be employed. The acid is soluble in about 25 parts of cold 
water. Corrosive-sublimate baths are employed in the strength of 1 
drachm (4.) of the mercurial to 30 gallons of water. Local baths thus 
medicated are often employed in the cleansing of ulcerated and suppur- 
ating surfaces with a view to subsequent dressing. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, carbolic acid, 
hydrocyanic acid, zinc, bismuth, mercury, lead, and alkaline bicarbon- 
ates with the sodic biborate. It is rendered stimulating by the ad- 
mixture of alcohol, most of the acids and alkalies in stronger solution 
than in the soothing or sedative lotions, and also by a large number of 
substances which operate upon the surface either mechanically or 
chemically. Water is also rendered astringent when tannin, lead, and 
similar medicaments are dissolved in it ; and by its union in various 
proportions with soaps and alkalies a solvent effect is produced, either 
upon the cuticle itself or upon pathological or foreign products upon 
its surface. 

Soaps. — Soft soap (sapo viridis, sapo mollis) made by the addition 
of caustic potash in an excess of between 3 and 4 per cent, to an 
animal fat, is a substance exceedingly useful in the treatment of skin- 
diseases. It is used for the purpose of producing either a detersive or 
stimulating, and at times a slightly destructive effect either upon the 
surface of the skin itself or upon pathological accumulations upon the 
surface (crusts, scales, etc.). It may be used as a plaster or with 
water : and this last either in substance or by the aid of the widely 
known "Spiritus Saponis Alkalinus" which Hebra first devised: 2 
ounces of green soap to 1 ounce of alcohol, flavored with spirit of lav- 
ender. The hard or soda soaps are employed chiefly for toilet purposes. 



100 GENERAL THERAPEUTICS. 

" Over-fatty " or " superfatted " soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight excess 
of imsaponified fat. They are exceedingly mild in their detersive 
action upon the skin, though the lather produced in their use is not so 
abundant as that with the alkaline soaps. These are usually proprie- 
tary articles. 

Medicated Soaps, containing carbolic acid, glycerin, tar, sulphur, 
and various oils, are sold in the shops ; but they usually contain so 
small a portion of the individual medicament from which each is 
named that they are practically worthless except for purposes of ablu- 
tion. Under cold pressure they may be made to contain medicinal 
substances in therapeutic proportions, but other forms of administra- 
tion of such medicaments are preferable. 

Fatty and Oily Substances are applied to the skin either directly 
by pouring, or by friction, or by the mediation of compresses, bandages, 
etc., which are saturated or are spread with the material to be applied. 
The oils may be used for either nutritive, soothing, or stimulating 
effects. To the first and second classes belong cod-liver, lard, olive-, 
almond-, linseed-, neat's-foot, castor-, and similar oils; to the third class 
belong the oil of tar, of cade, of white birch, of the cashew-nut, and 
of juniper. 

Fatty substances are also applied in the form of ointments or 
pomades. They are compounded with various medicinal substances, 
according to the requirements of each case, such as the salts of mer- 
cury, zinc, copper, lead, and sulphur ; pyrogallol, chrysarobin, carbolic 
and hyposulphurous acids ; tar, camphor, iodoform, balsam of Peru, 
chloral hydrate, and the extracts of opium, belladonna, etc. 

The products of petroleum refinement represented by Vaselin, 
though not true fats, are employed increasingly for similar purposes. 
They are particularly useful as bases for ointments for application to the 
hairy portions of the body, such as the scalp, where more consistent 
salves paste the hair to the surface in an unsightly mass. 

In the class of soothing ointments which are required in many 
cases in which the skin is the seat of a severe pruritus or is produc- 
tive of burning sensations, may be named the diachylon, benzoinated 
zinc-oxide, " cold-cream," lanolin, cucumber, petroleum, diachylon, 
spermaceti, cacao-butter, and olive-oil with vaselin ointments. Those 
medicated with the several oleates and with the salts of bismuth, zinc, 
or lead, are often of great value. As a rule, however, in most cases 
calling urgently for soothing applications fat-containing dressings are 
not to be preferred to lotions or dusting-powders, or the two last named 
in combination. Ointments are rubbed gently over the affected sur- 
face, but they are more efficient when spread on bits of soft muslin and 
kept in contact with the skin. 

McCall Anderson's ointment has long been employed for soothing 
inflamed surfaces. It is compounded by adding 1 drachm of bismuth 
oxide (4.) to 1 ounce (30.) of oleic acid, 3 drachms (12.) of white wax, 
9 (36.) of vaselin, and a few minims of the oil of roses. 10 parts of 
lanolin, with 20 of lard and 30 of rose-water, make another useful 



EXTERNAL TREATMENT. 101 

combination. Many of these ointments in the past have been found to 
be irritating on account of the fatty acids which they develop, especially 
in hot weather. They may now all be kept perfectly sweet by the 
addition of a small quantity of formalin to each jar compounded. 

The following formulae are also useful : Boric acid, white wax, and 
paraffin, each 10 parts ; oil of sweet almonds, 60 parts (H. Hebra). 
Bismuth oxide, 1 drachm (4.) ; white wax, 6 drachms (24.) ; vaselin and 
olive-oil, of each 1 ounce (30.). Boric acid, 1 part ; glycerin, 24 parts ; 
anhydrous lanolin, 5 parts ; vaselin, 70 parts (Duhring's " boroglycerin 
cream ointment"). Other fatty applications are prepared by adding 
olive-, sweet-almond, or cotton-seed oil, as well as lard and lanolin, to 
lime-water in nearly equal proportions. These furnish a thick emulsified 
substance which requires to be well shaken before application. Any 
one of these emulsions may be medicated at will by the addition of 
zinc, bismuth, calamine, or other insoluble substance which is mechani- 
cally mixed with the fatty emulsion when the whole is well shaken. 

Stimulating ointments are usually made by the addition of such 
substances as tar, mercury, resorcin, salicylic acid, pyrogallic acid, 
chrysarobin, or sulphur to any one of the several salve-bases in com- 
mon use. 

Glycerin, even the best, when applied in its purity to the skin is 
usually irritating. It is, however, exceedingly useful when diluted or 
made a component part of lotions and ointments. When combined 
with starch in different proportions it makes a series of combinations 
known as glyceroles, or glycerolates. These combinations are pasty, 
semisolid substances which are capable of varied medication, as in the 
glycerole of lead subacetate. They are useful chiefly as protectives 
of the skin-surface. Glycerin, used in a fluid soap, is an exceedingly 
valuable agent when a milder effect is desired than that produced by 
the spirit of soap described above. The Vienna preparation known as 
Sarg's fluid soap is an admirable substitute of this sort when a soft 
shampoo is required for the scalp. 

Pastes employed for local application in diseases of the skin have 
greatly been perfected by Lassar and Unna. 1 

These pastes are valuable especially in the exudative affections, in 
which salves are often either not w r ell tolerated or actually prove irritating 
to the skin. The pastes, when applied to such surfaces, form a pro- 
tective and adhesive dressing, w r hich may be medicated as desired. One 
of the best and most serviceable pastes is : 

R Zinc, stearat. cum acetanilid., ) 

01. oliv., \ aa 3ij. 8 

Unguent, aq. ros., J | M. 

Or the following modification of Lassar's paste : 



K Zincioxidi,j aa5ij; 

|ss; 
1 Monatshefte, 1884, iii., p. 38. 



Acid, salicylic, gr. x ; 

Vaselin., Jss ; 16 



M. 



102 GENERAL THERAPEUTICS. 

^qual parts of lanolin, vaselin, talc, and zinc oxide form a base that 
is stiffer than the preceding and adheres better. To these bases may be 
added various remedies in desired proportions. 

Duhring's modification of the original Lassar paste is : boric acid, 
9j (1.); starch and zinc oxide, each gij (8.); vaselin, 3j (33.). Unna 
employs : starch, 3 parts ; glycerin, 2 parts ; water, 15 parts ; boiled 
down to 15 parts. Half the quantity of any desired medicament may 
be added to the amount ordered. Paraffin may be added in the making 
of very stiff pastes in the proportion of equal parts of this substance 
and water ; twice the quantity of lanolin ; and about fa of white wax. 

Other pastes are prepared with kaolin (terra alba, or Armenian bole 
of red color when it is desirable to have the application resemble the 
color of the skin), gum, lead, dextrin, glycerin, and other substances. 
Formulae for each are here appended. 

Kaolin in a pure state, with equal parts of vaselin or glycerin, or 
with almond-, olive-, or linseed-oil, in the proportion of two to one, is 
readily applied in a thin layer over the skin. 

For making lead-pastes, litharge is boiled with twice the quantity of 
vinegar until the latter has evaporated and there is left a damp but 
drying paste, which may be, on occasion, remoistened with a small 
quantity of vinegar, e. g.: 

R Lithargyr. subt. pulv., ^jss ; 451 

Aceti, ,?ij ss >* 751 

Coque usque ad consistent, pastae: deinde adde ol. lini [v. glycerini, v. ol. 
olivae], 10.— M. 

In the two forms of paste above described the adhesive and desic- 
cative qualities are obtained from the main ingredients, but in those 
resulting from combinations of gum, starch, and dextrin these results 
are for the most part obtained by the addition of other ingredients, such 
as sulphur, zinc, etc. A good basis, semisolid, rapidly drying, and 
fixing its ingredients well upon the surface, is the following: 



R Zinci oxidi, 


3jss; 


45 


Acid, salicylic, 


3ss; 


2 


Amyli oryzse, 1 
Glycerini, j 


aa 3iij ; 


12 


Aq. dest., 


3ijss; 


75 


Coque ad., givss (145). 






)r a sulphur-paste : 






R Sulphur, praecipit., 


Ijss; 


45 


Calc. carb., 


3ss; 


2 


Zinc, oxid., 


Uss; 


15 


Amyli oryzae, 


3iij ; 


12 


Glycerini, 


Iss; 


15 


Aq. dest., 


Jijss; 


75 


Coque ad., giv (120). 







To make use of dextrin, the official pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half- 



EXTERNAL TREATMENT. 



103 



weight of glycerin is required if powders are also combined wil)h the 
paste — e. g.: 



R Zinc, oxid., ^jss; 

Dextrin., ) .- z 

Aq.dest., j aa ^ SS > 

Glycerin., 3jss; 

Sulphur, sublim. [vel sod. ) _ 

sulpho-ichthyol.], j 5SS; 

Coque. 

A mixture of dextrin and lead is thus prepared : 



R Lithargyr., 
Acet., 

Coque ad remanent., 50. 
Adder 

Dextrin., 

Aq. dest. 

Glycerin. 
Coque. 



5i; 



e ( 



aa ^ss 



151 



If too consistent, these pastes are made to spread easily by the 
addition of a few drops of hot water. 

For gum-pastes, gum Arabic is used in the proportion of 1 part 
of the mucilage and glycerin to 2 parts of the powder selected, mixed 
without heat — e. g. : 

R 



R 



R 



Zinc, oxid., 


3 jss ; 


45 


Hydrarg oxid. rub., 


5ss; 


2 


Mucilag. acac, ) 
Glycerin., j 


aa ^ss; 


15 


Cret. praeparat., \ 
Sulphur, sublim., } 


aa 3ss; 


2 


Picis liquid., 


3ij; 


8 


Amyli, 


^ss;- 


15 


Mucilag. acac, ) 
Glycerin., j 


aa ^ss; 


15 


Acid, salicylic, 


^ss; 


15 


Glycerin., 


^ss; 


15 


Mucilag. acac, 


Sj; 


30 


01. ricini, 


Sijss ; 


10 



M. 



M. 



M. 



The following details are to be noted respecting the availability of 
these pastes for different ingredients : Lead is best used as an acetate, 
either in a simple paste or with dextrin, the carbonate, oleate, and 
iodide combining well with both. Zinc oxide and sulphur combine well 
with kaolin, lead, starch, dextrin, and gum. Sulphur combines well 
with the three last named, poorly with kaolin, and not at all with lead. 
Ichthyol suits well with all save the gum-pastes. Naphtol, calomel, 
corrosive sublimate, red and white precipitates, carbolic acid, chloral 
hydrate, camphor, and salicylic acid can be incorporated with all, the 
last named in smaller proportion with gum-paste. Tar is better united 
with starch, dextrin, and gum than with the others. Iodine and iodo- 



104 GENERAL THERAPEUTICS. 

form naturally do not suit well with the starch- and dextrin-pastes. 
Chrysarobin and pyrogallol are united with kaolin and gum-pastes, 
and should not be added to them. Fatty and soapy substances, if 
commingled in large amounts with these pastes, injure their special 
properties. 

Glycogelatins are useful for protecting a surface and excluding the 
air. They are made with varying proportions of glycerin, gelatin, zinc 
oxide, and water. When cold they are solid, but when melted on a 
water-bath can be painted readily over a surface, upon which on cool- 
ing they form an adherent protective coating. Before the gelatin has 
hardened on the skin it is well to pat it with cotton, or to lay over it a 
piece of thin gauze or muslin to form an additional protection and to 
prevent the paste sticking to the clothing. A firm but soft and flexi- 
ble gelatin is made by mixing on a hot-water bath 1 part of zinc 
oxide, 2 of gelatin, 3 of glycerin, and 4 of water. More gelatin in the 
preparation makes it firmer and causes it to dry quicker. A greater 
proportion of glycerin, on the other hand, interferes with the complete 
drying of the surface, but makes a softer preparation, more acceptable 
to some skins and very useful where a bandage can be applied. Zinc 
oxide helps give body to the gelatin, but if used in too large proportion 
interferes with the coherence of the preparation, so that it cracks when 
dry. To the glycogelatins may be added white precipitate, sulphur, 
ichthyol, thiol, chrysarobin, iodoform, or other antiseptics. Some drugs, 
as salicylic acid, resorcin, naphtol, and carbolic acid, tend to destroy 
the coherence of the gelatin. Fox says that this obstacle may be 
removed by adding to the paste 5 or 10 per cent, of fresh lard. 

Varnishes, containing glycerin and a single gum, are often very 
serviceable in protecting the skin. They are especially useful on the 
face, as they are transparent and inconspicuous. 

Pick's varnish (linimentum exsiccans) is made as follows : 

R Tragacanth, 5 parts. 

Glycerin, 2 " 

Distilled water, 93 " 

The tragacanth is soaked in a portion of water from ten to twelve 
hours and triturated to a perfectly smooth mass before adding the glyc- 
erin and other ingredients ordered. The jelly may be prepared without 
delay by triturating the tragacanth with boiling water, but the result is 
not quite so good. 

This jelly is applied without heating and quickly dries on the skin. 
An improvement on this varnish is Elliott's bassorin paste, which keeps 
better than the former. The formula is as follows : 

B Bassorin, 
Dextrin, 
Glycerin, 
Water to make 

This should be kept in a tightly closed jar, as it dries rapidly on 
exposure to the air. Like the other pastes, it not only serves as 






3Jss ; 


45 


3vj; 


24 


Sijss ; 


10 


3iij ; 


90 



EXTERNAL TREATMENT. 105 

a protective coating, but also as a base for the application of other 
remedies. 

Powders are mechanically dusted over the surface of the skin 
for the purpose of protecting it, and occasionally, also, to produce 
an astringent or antipruritic effect. To be serviceable, they should 
generally be rendered impalpable by sifting them carefully through a 
tine silk bolting-cloth. They are composed of starch, talc, magnesia, 
lycopodium, calamine, bismuth, boric acid, the several stearates, cam- 
phor, tannin, zinc oxide, iodoform, rice, kaolin, magnesium silicate, 
orris root, salicylic acid, aristol, europhen, and similar substances. The 
articles sold by grocers as " gloss starch " and " corn-starch farina " 
are usually much more finely bolted than the dusting-powders extem- 
poraneously prepared by chemists. All starchy substances are open 
to the objection of forming little pasty rolls or " cakes " when wetted 
with serum or with sweat. Lycopodium, which consists of irregularly 
shaped globular pollen-sporules, never behaves in this way, and is, 
for that reason, deservedly popular. Zinc stearate with acetanilid is 
excellent for similar reasons, and when dusted on the surface forms 
a dressing impervious to moisture. 

Medicated powders may be first dissolved in alcohol, ether, or 
chloroform. The solution is then mixed with starch or with French 
chalk. Evaporation of the menstruum is conducted without artificial 
heat, and a fine medicated starch or a chalk-powder results. 

For absorbent purposes Grundler 1 has shown that by far the most 
effective powder is magnesium carbonate. 

Plasters are employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin-plasters are less useful in skin-diseases be- 
cause more irritating than the lead-plasters. In the zinc-oxide adhe- 
sive plaster the irritating effects of the resin have been entirely over- 
come, and the result is a plaster which has excellent adhesive qualities 
and which rarely causes irritation even to sensitive skins. It thus 
answers admirably where simple protection is desired, and may be 
safely employed in order to retain other dressings in place. Unna's 
plaster-mulls are described below. The mercurial plasters are useful, 
especially in syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by Unna. His Salve-muslins, 
or salve-mulls, are strips or bandages of muslin thoroughly impreg- 
nated and thickly spread with ointments medicated with almost every 
desirable substance, from zinc oxide to tar, thymol, salicylic acid, and 
mercury. They are elegantly made, and when exported are sur- 
rounded by impermeable tissue, so that they remain fresh and sweet 
for several weeks, or even for months if kept in a cool place, but de- 
teriorate rapidly if exposed to the air of a warm room. They are 
efficacious, and, as a rule, well liked by patients. They are available 
in skin-diseases of the exudative class affecting the extremities, but 
should be avoided when not recently prepared. 

Unna's Plaster-mulls seem to be less useful. They are plasters 

1 Monatshefte, 1888, vii., p. 1029. 



106 GENERAL THERAPEUTICS. 

thinly spread on gutta-percha cloth, and manufactured with a wide 
range of medicinal constituents. They serve a good purpose in the 
protection of parts of the skin exposed to friction. 

Salve-pencils (stili unguentes) and Paste-pencils (stili dilubiles), 
the latter destitute of fat and soluble when moist, the former insol- 
uble in water and compounded of fatty substances, are pencil-sized cray- 
ons made with wax, gum, and starch, for application to limited areas 
of the skin. The several mercurials, arsenious acid, cocaine, salicylic 
acid, and other medicaments may be applied in this way to the surface. 

Poultices are not often ordered in the management of diseases of 
the skin, except for the purpose of softening crusts with a view to their 
removal. They are made, both warm and cold, wijth linseed-meal, 
potato-starch, bread and milk, oatmeal, and cornmeal. These applica- 
tions are objectionable in all conditions in which a macerative eifect of the 
epidermis is produced ; and also in whioh micro-organisms may find a 
culture-field in the mass of the poultice. Poultices, in any needful 
case, may be made antiseptic by the addition of formalin, boric acid, or 
mercuric chloride. 

Lanolin, or wool-fat, was first introduced as a salve-base by -Lie- 
breich, of Berlin. It is a substance obtained from keratinic tissues, 
and contains cholester in-fat instead of glycerin, with but 30 per cent, 
of water. It has a bright-yellowish color, a distinct odor of the sheep, 
and is neutral ; when pure it is never acid in reaction. The refined 
product now placed upon the market is free from cholesterin com- 
pounds and requires no fatty addition. This substance is readily 
absorbed from the surface of the skin, and, either pure or medicated, 
may be regarded as a useful addition to the bases of ointments. The 
adeps lanse answers the same end. 

Oleates of zinc, mercury, copper, lead, and other metals have been 
employed with advantage in the topical treatment of disorders of the 
skin. Of these, the oleates of mercury and of lead are decidedly the 
most valuable. The latter is represented by Hebra's white diachylon 
ointment. The mercuric oleate is serviceable in syphilitic, parasitic, 
and other disorders. 

The Vasogen products bid fair to supplant the oleates in their 
ready absorption from the skin-surface. In mercurial inunction vaso- 
gen-mercury capsules supply the exact amount required for employ- 
ment at each sitting. 

Collodion and Traumaticin are employed for the purpose of ap- 
plying a remedy to the skin, and at the same time for protecting or 
contracting the surface to which the application is made. Traumaticin 
is the name given to a solution of gutta-percha in chloroform, in the 
proportion of 10 per cent. In this way bismuth, cantharides, sulphur, 
chrysarobin, zinc oxide, white precipitate, iodine, and other substances 
may with advantage be applied to the surface, and the action of each 
be definitely limited to the margins of a single patch of disease. 

Tar in its several varieties, crude and distilled, together with its 
derivatives, occupies an important place among efficient topical agents. 
In general, it seems to exert upon the epidermis a local influence, 
which extends more deeply as the remedy is continuously applied. At 






EXTERNAL TREATMENT. 107 

times both irritative and inflammatory effects are thus induced, and 
even systemic intoxication Avhen absorption from the skin occurs. Pix 
liquida, or the oleum picis, is the favorite article of this group with 
most American physicians ; but the oleum cadini, or oil of juniper, 
and the oleum rusci, or oil of birch, are rather more generally em- 
ployed by experts. The last-named, found in purity and abundance 
and to be had at a low price in American markets, is recommended 
above the others. In Vienna the distilled oil is preferred, but there is 
good reason to believe that the crude oil is decidedly more efficacious. 

The skill of a physician intrusted with the management of a disease 
of the skin might almost be measured by his success in the use of tar. 
He who has not had experience in its employment is urgently advised 
to select one member of the tar-family and learn thoroughly how to 
apply that, singly and in combination, either as a lotion or in salve. 
Properly employed, it will favor involution of lesions, lessening hyper- 
emia, infiltration, scaling, and discharge. It serves admirably as an anti- 
pruritic. It may, however, produce severe inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with some soothing or astringent powder, and with this end in view 
nothing is better than chalk. Spender's hints l for making such an 
ointment are admirable : Finely levigated chalk is strewed into melted 
lard in a stone jar, the whole being stirred until it is cold. Then at 
first the smallest quantity of tar sufficient to make a brownish smear 
of color is added to the quantity of salve employed for use. This 
color can be successively deepened at will. Auspitz advises the use 
of the tars in a pure state, applied in very small quantities with a 
strong bristle-brush and well rubbed in. In combination with one of 
the most valuable of all substances for topical use in cutaneous thera- 
peutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson 
salve modified (q. v.) represents such a combination. 

A group of substances which occupy a therapeutic position inferior 
to the tars, but which serve an important end in the management of 
cutaneous diseases by the production of similar effects, are carbolic 
acid, creosote, salicylic acid, benzol, naphtol, iodol, thiol, chrysarobin, 
pyrogallol, resorcin, and jequirity. 

Ichthyol, fish-oil, introduced to the profession by Unna, is the 
distillate of a bituminous and sulphurous deposit of petrified fishes 
and marine fossils found in the Tyrol. Its chemical formula is 
C 26 H 36 S 3 Na 2 6 . It has a tarry appearance, odor, and consistency. It 
is soluble in water, partly so in ether and alcohol, and can be incor- 
porated in any desired proportion with fat, vaselin, and lanolin. It 
has been used both pure and diluted ; and several proprietary articles 
(plasters, soaps, salves, and medicated cotton) are in the market. It 
has been used both in America and in Europe in cases of leprosy, 
pruritus, acne, sycosis, eczema, psoriasis, and a number of other cuta- 
neous disorders. 2 It is used in solutions of from 10 to 50 per cent. 

1 Practitioner, June, 1883, p. 402. 

2 See Baumann and Schotten, Monatshefte, 1883, ii., p. 257 ; Unna, Ibid., 1882, i., 
p. 225; Deut. med. Zeit., 1883, iv., p. 217; Samml. klin. Vort., 1885, No. 252: Lorenz, 
Deut. med. Wchnschrft., 1885, xi., p. 627 ; Stelwagon, Jour. Cutan. Dis., 1886, iv.,p. 326, 
Zeisler, Chicago Med. Jour, and Exam., 1886, liii., p. 32. 



108 GENERAL THERAPEUTICS. 

and in salves of from 5 to 20 per cent, strength. As before stated, it 
is also administered internally, more particularly in the management 
of rheumatism, in doses of from 15 to 20 drops. It does not seem to 
have a disturbing effect upon the stomach. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four months' old infant sank into a 
stupor two hours after its head and limbs were smeared with a salve 
composed of one part of ichthyol to five of vaselin. 

Thiol makes an excellent substitute for ichthyol for most purposes, 
and lacks the unpleasant odor of the latter. 

Resorcin in ointments of the strength of from 5 to 20 per cent, 
serves as an antipruritic and alterative. Stelwagon reports an anodyne 
effect following its use. The same experimenter has modified Ihle's 
formula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms (4.-8.) 
of castor-oil, 5 minims (0.33) of Peruvian balsam, and 4 ounces (120.) 
of alcohol, for use in alopecia and seborrhoea of the scalp. It is a 
valuable parasiticide in lotions of the strength of from 5 to 10 per 
cent., and is especially useful in disorders of the scalp due to seborrhoea. 

Naphtol, or /9-naphtol, as it is termed chemically, first introduced 
by Kaposi, is chiefly valuable in scabies, but has also been used in the 
management of eczema, psoriasis, and other exudative affections. Van 
Harlingen l has found it to answer well in seborrhoea of the scalp. 
Neisser has described renal disorders as resulting from its use in chil- 
dren, but MM. Josias and Nocard 2 report that in ordinary medicinal 
doses it is harmless. The fact that the naphtol preparations are odor- 
less and do not stain the skin is to be set down in their favor. 

Boric Acid is of great value in diseases of the skin and is exten- 
sively employed as a lotion and in ointments and powders. As a rule, 
it exercises a sedative effect upon the surface to which it is applied. 
Over mucous surfaces it is occasionally a source of moderate irritation. 

Salicylic Acid operates especially upon the keratinized tissues of the 
epidermis, softening and separating the external portions of the horny 
layer from its deeper connections. For this reason it has a special 
value in all the hyperkeratosie dermatoses. In somewhat weak strength 
it is employed as an antipruritic agent. It is most often employed in 
salves or pastes but is also used in lotions, being soluble in 2.5 parts 
of alcohol, 2 parts of ether, or 450 parts of water. It is a common 
ingredient of most of the popular corn- and wart-cures. 

Carbolic Acid, since in value as an antiseptic it has been largely 
surpassed by other articles, is chiefly employed to-day upon the skin 
as an antipruritic. It is applied in the form of lotion, salve, and 
paste, but much more often in lotions having the strength of from 
10 to 20 grains to the ounce (0.66-1.33 ad 30.). Other acids— nitric, 
sulphuric, lactic, acetic, muriatic, benzonic, tannic, chromic — are em- 
ployed either for caustic, destructive, or stimulating effect, usually in 
liquid form. Tannic acid, however, is occasionally employed as a 
powder, in which form its astringent quality is combined with the 
soothing or antiseptic effect of other substances in powder. 

1 Amer. Jour. Med. Sci., 1883, n. s., lxxxvi., p. 479. 

2 Annales, 1885, s. ii., vi., p. 257. 



EXTERNAL TREATMENT. 109 

Chrysarobin, Pyrogallol, and Anthrarobin are useful as cutaneous 
stimulants capable of determining in the skin to which they are applied 
a characteristic dermatitis limited to the site of the application. Chrysa- 
robin is especially useful in the local treatment of psoriasis, lepra, 
and the disorders due to vegetable parasites. It is employed in from 
1 to 10 per cent, strength, in salve, lotion, or in collodion. A useful 
combination in the parasitic disorders of the scalp due to the micro- 
sporon Audouini or to the trichophytons is a solution of chrysarobin in 
oil of turpentine, about 1 part in 250. A chief objection to its use is 
the consequent staining of the skin and articles of apparel. On the 
scalp the hairs are turned to a yellowish-green shade. Pyrogallol 
oxidizes after exposure and turns the skin a blackish color. It is 
useful in many cases of lichen planus, eczema, and the diseases due to 
the vegetable parasites. It has been employed in the strength of 50 
per cent, in the removal of epitheliomata. Anthrarobin, though in- 
ferior to both of the other articles named, is effective in the same gen- 
eral manner. 

Iodine, especially in the form of tincture, is useful as a local appli- 
cation in certain of the seborrheas, and as a parasiticide. It is often 
employed with mercury in the form of an ointment. The ointments 
compounded of the salts of iodine, with mercury, though of unques- 
tioned efficacy, are less employed to-day than formerly. 

Jequirity (Abrus preeatorius), employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, has 
been used by Shoemaker l in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar 
to a smooth paste, was added to sufficient water to make four parts. 
This emulsion was used for local application. 

Sulphur, popularly employed chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous thera- 
peutics as an external agent in a wide range of non-parasitic disorders. 
Hebra once regarded it as valueless in eczema, but his opinions on this 
point are not now generally accepted. Precipitated sulphur is to 
be preferred to the other compounds of the pharmacopoeia. It may 
mechanically be incorporated with salve-bases, or chemically combined 
with vaselin and other petroleum-products, a process by which, as 
experiments have shown, its therapeutic value is not increased. It is 
also applied after mechanical union with various substances as a lotion. 
It is irritating to the acutely inflamed skin, but is much better tolerated 
than the tars in conditions of subacute or chronic exudation. 

Formaldehyd. is a valuable antiseptic agent most commonly em- 
ployed as formalin, a proprietary preparation representing 40 per cent, 
of the compound. Formalin in the strength of 1 per cent, commonly 
produces a slight irritation over the thin skin of the face ; and after 
application in the strength of 2 per cent., which should be rarely 
exceeded on the cutaneous surface, there follows a decided sensation 
of burning with a resulting transient erythema. It is a remedy of 
the highest value in the treatment of syphilodermata, acne, seborrhoea, 
1 Lancet, 1884, ii., p. 185. 



110 GENERAL THERAPEUTICS. 

the disorders produced by the vegetable parasities, several of the 
eczemas, impetigo, and other affections. It is well to color the solution 
with a trace of fuchsin. 

Pyoktanin-blue is employed in aqueous saturated solution as a 
parasiticide in those disorders of the skin especially which affect regions 
beneath the clothing or which may be protected by dressings from ex- 
posure to the eye. It is highly valuable as a local and painless appli- 
cation in circumscribed patches of weeping or scaly eczema, in many 
of the ulcerating syphilodermata, in lupus, and in ringworm. It 
should be applied daily in several coats, each coat being permitted to 
dry before the next is superimposed. 

Potassium Permanganate belongs to the same category as pyok- 
tanin-blue, with the disadvantage that it is in some strengths produc- 
tive of pain, while the pyoktanin solution is unproductive of pain. 
From 2 to 10 per cent, solutions of the potassic salt may be painted 
on the affected surface one or more times daily till the desired effect 
is produced. The indications for its use are those which the pyok- 
tanin solution is intended to meet. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and non-syphilitic. The prepa- 
rations of mercury employed as topical agents in the treatment of 
diseases of the skin are of the highest value. They include corrosive 
sublimate, calomel, the red and yellow oxides, the biniodide and cinna- 
bar, the white and red precipitates, and the nitrate. The most com- 
monly employed of their combinations are the " black wash," oint- 
ment of the nitrate, and mercurial ointment. Fumigation of the 
surface by vaporization of either cinnabar or calomel or the two in 
combination is chiefly employed in the local treatment of syphilo- 
dermata. The bichloride is most often applied as a lotion ; calomel 
and white precipitate in ointments ; though calomel is often effec- 
tively combined with talc or starch as a powder. Starting nitric oxid 
of mercury ointment represents a combination of two mercurials : red 
mercuric oxide, 6 grains (0.40) ; mercury bisulphate, 4 grains (0.25) ; 
simple cerate, 1 ounce (30.). Corrosive sublimate as a parasiticide is 
of great importance in the treatment of several cutaneous disorders due 
to the presence of micro-organisms, as, for example, lupus vulgaris. 

Chloral- camphor and Phenol- camphor have value chiefly as anti- 
pruritics. The former is obtained by rubbing together chloral hydrate 
and gum-camphor (Bulkley) until they form a clear liquid of pungent 
odor. Phenol-camphor is made by gradually adding camphor to melted 
crystals of carbolic acid, a colorless liquid resulting having the fragrant 
odor of camphor without that of the acid. It is a useful local anaes- 
thetic agent, being insoluble in water, but freely soluble in chloroform, 
ether, and alcohol. 

Many Agents are employed upon the surface of the integument to 
produce in various degrees a caustic or destructive effect. Among 
these may be named the ther mo-cautery (Paquelin-knife), galvano- 
caustic apparatus, the mineral acids and alkalies, sodium ethylate, 
arsenic, zinc chloride, several mercurial compounds, mercuric nitrate, 
mercuric chloride, antimonious chloride, cupric sulphate, and argentic 



EXTERNAL TREATMENT. Ill 

nitrate. Several of these substances in weak solution are employed as 
milder agents for the production of irritative or even inflammatory 
effects. To the latter class should be added iodine in tincture, chloro- 
form, tartar emetic, croton-oil, and cantharides. These destructive 
effects are of advantage in the treatment of disorders of the integu- 
ment due to parasites, either animal or vegetable. Of those employed 
for this purpose, and not mentioned above, may be named petroleum 
and staphysagria, for the destruction of lice; sulphur, styrax, and 
balsam of Peru, for the destruction of acari ; and sulphur and its com- 
pounds and a number of derivatives from tar, for the destruction of 
vegetable parasites. 

Counter-irritation over the Vasomotor Centres, as recommended 
by Crocker, is an efficient means of relieving fixed and obstinate cuta- 
neous disorders. It may be produced by the action of sinapisms, 
blisters, or caustics over the region selected for such irritation. 

A large list of medicinal substances might be added which are oc- 
casionally employed in cutaneous affections, some very rarely, the most 
with questionable effect. Among them may be named alcohol, which 
is of high value as a disinfectant, and hydrogen peroxide, having a 
similar effect ; ether, the opium alkaloids, cocaine, belladonna, cannabis 
indica, and aconite, for anaesthetic and antipruritic effect; and ergot, 
cantharides, mustard, croton-oil, tartar emetic, benzoin, capsicum, rose- 
mary, and the several salts of lead. Many of the articles named, such 
as cantharides, rosemary, and capsicum, are employed as lotions for the 
scalp in the several alopecias. 

The salts of zinc (sulphate, sulphocarbolate, acetate, oxide), of copper, 
alum, lead, bismuth, and other metals are of service in diseases of the 
skin as productive of both astringent and stimulating or even of caustic 
effects. The careful adjustment of the dosage in each instance is of the 
highest importance, and is practically indispensable for the production 
of beneficial effects. 

Electrolysis is a method of the greatest value in the treatment of 
a large number of cutaneous affections, such as hypertrichosis, telan- 
giectases, molluscous tumors, warts, etc. It is accomplished by the 
aid of the galvanic battery in the manner described in this work in the 
pages devoted to the first of the disorders named. 

The Minor and other Surgical Operations required in the manage- 
ment of some affections of the skin are detailed in the treatises devoted 
to that subject. Among such procedures may be named skin-grafting, 
both by the methods of Reverdin and Thiersch, and the several devices 
of plastic surgery. Strictly dermatological procedures to which resort 
must often be made are : epilation in hyphogenous sycosis and other 
affections ; massage, especially by the massering-ball ; the operations 
on the face, especially in acne, when opening small abscesses, removing 
comedones, and incising papules ; and multiple scarification, as in telan- 
giectases and other lesions. 

Numerous Surgical and other Appliances are found useful as 
adjuvants in the treatment of skin-diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in the 



112 GENERAL THERAPEUTICS. 

retention of dressings or external medicaments. Thus, the ordinary 
roller-bandage is applicable to many portions of the body ; the suspen- 
der, or suspensory bag, to the scrotum ; elastic or inelastic stockings 
to the feet and legs ; kid, rubber, and thread gloves to the feet and 
fingers ; and various skull-caps, face-masks, and mittens are employed 
in the case of infants and children to protect affected surfaces from the 
traumatisms of scratching. 

Apart from the surgical apparatus required for ablation of tumors 
or severe operations, a number of instruments are required for the 
daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged spoons 
are for erasion of the surface, and should, for general use, have in each 
a fenestrum large enough to permit the escape from the floor of the 
spoon of all collected substances. The small-sized spoons, however, 
with solid bowl and sharp edges, largely used in Vienna, are prefer- 
able for use, especially about the face, in many skin-affections. Epilat- 
ing-forceps, with easy springs and smooth blades meeting in perfect 
apposition ; a set of Piffard's comedone-extractors, provided at each 
extremity with a differently sized, minute, spoon-shaped and perforated 
bowl, the convex surface of which is pressed over the comedo with the 
orifice immediately over the black head of the plug. This is a great im- 
provement over the old-fashioned comedo-extractor shaped like a watch- 
key, and the discomfort to the patient by its use is greatly reduced. 
A set of half-inch and four-inch lenses for examining the surface of the 
skin ; needle-holders with light handles for firmly grasping the needles 
used in opening pustules, etc. The needles, some of them, should 
be flat, with a double-cutting edge, others be rounded neatly on an 
emery-wheel, and all of them carefully disinfected if used more than 
once. Too many precautions cannot be taken in the practice of der- 
matology with respect to the disinfection of all instruments made to 
penetrate the skin. Probes, exploring-needles, fine dressing-forceps, 
delicate straight and curved scissors, and other instruments from the 
ordinary pocket-case of the surgeon, are indispensable. The instru- 
ments required for use in connection with the galvanic battery are 
enumerated in the chapter on Hypertrichosis. 

Fig. 23. 



Irido-platinum needle. 
Fig. 24. 

Milium-needle. 
Fig. 25. 



^r 



Searifying-spud. 



EXTERNAL TREATMENT. 
Fig. 26. 



113 




Epilating-forceps, 
Fig. 27. 




Piffard's grappling-forceps. 
Fig. 28. 




Piffard's cutisector. 
Fig. 29. 




Fig. 30. 




Dermal curettes. 
Fig. 31. 




1IEM/INN-CQ-JW 

Hess's glass pleximeter, for observing the skin under pressure. 




Piffard's modification of Unna's comedo-extractor. 
Fig. 33. 

o *j4 of real size. 

Keyes's cutaneous punch. 

Fig. 34. 




Hyde's massering-ball. 



114 GENERAL THERAPEUTICS. 

Radiotherapy l (Treatment by X-rays) has acquired great impor- 
tance in cutaneous medicine. Among the diseases in the management 
of which it has distinct value are epithelioma, lupus vulgaris, and other 
forms of cutaneous tuberculosis, coccogenous and hyphogenous sycosis, 
acne vulgaris, rosacea, psoriasis, hypertrichosis, lupus erythematosus, 
ringworm, and favus. The list includes diverse morbid conditions, 
but these in turn actually are remedied in many cases by one or the 
other of the therapeutic properties of the agent. X-rays per se are 
not germicidal, but indirectly, through tissue-reaction, they may pro- 
duce such effects in a high degree, as shown by the partial or com- 
plete arrest of purulent discharge from the surface of carcinomatous or 
other ulcers subjected to their action. They produce degeneration in 
cells of embryonic type without destroying the healthy stroma in which 
they have developed ; cells also of higher differentiation are affected 
early. As a consequence, hair-follicles and sebaceous glands may 
become partially or wholly atrophied under the influence of the ray, 
the result depending upon its quantitative value. 

The Clinical Effects of the rays upon normal skin vary from 
slight erythema and pigmentation to deep-seated, destructive inflam- 
mation. The earliest evidence manifested is either pigmentation or 
erythema. The former may be lentiginous or exhibited as a diffuse, 
brownish discoloration of different shades, the amount of pigment 
varying as a rule with the complexion of the patient. Usually this 
disappears within a few days or weeks, though it may persist for sev- 
eral months. Erythema appears early and soon subsides, with super- 
ficial desquamation and pigmentation, if treatment be suspended in 
time. The process usually lasts from a few days to two weeks, and is 
accompanied by mild itching or pricking sensations. Should the 
inflammatory process progress to a further stage, vesicles appear on 
the erythematous area. These may be either superficial and short- 
lived, soon drying and disappearing, or more deeply situated, and 
associated with greater swelling and increased redness, the whole area 
becoming denuded of its superficial epithelium and showing an excori- 
ated and weeping surface (.r-ray dermatitis). This surface usually 
becomes covered with a yellowish or grayish adherent pellicle, com- 
posed of necrotic epithelium, which gradually retracts, its place being 
taken by normal cornified cells. In case the pellicle does not form, 
bluish islands of epithelium appear over the weeping surface, which by 
enlargement and coalescence cover the area. The new epithelium is 
smooth, delicate, bluish-w T hite in color, devoid of pigment and hair, 
and may remain sensitive to external influences for some time. The 
duration of this degree of dermatitis is from a few weeks to several 
months, and the subjective sensations vary ; usually a burning, ting- 
ling, or itching sensation is experienced, with occasionally marked 
tenderness and some pain. In a dermatitis of serious portent, the 

1 For complete presentation of the subject and bibliography, see : Freund, Grund- 
riss der gesammten Radiotherapie, Berlin and Vienna, 1903 ; Williams, The Rontgen 
Rays in Medicine and Surgery, New York, 1901 ; Pusey-Caldwell, The Rontgen Rays 
in Therapeutics and Diagnosis, Philadelphia, 1903 ; Stelwagon, Jour. Cutan. Dis., 1903, 
xxi., p. 345 (with discussion before the Amer. Derm. Soc.) ; Pusey, Ibid., p. 355 (with 
discussion before the Amer. Derm. Soc.) : Bronson, Ibid., p, 375. 



EXTERNAL TREATMENT. 115 

subcutaneous and deeper tissue is involved. The inflammation begins 
with erythema, vesiculation, and marked swelling ; the skin becomes 
cyanotic and brawny, and necrosis follows. The affected area is cov- 
ered with a dry, dark-colored, leathery, adherent mass of tissue, which 
may persist for months, is surrounded by a reddish inflammatory border, 
and is accompanied by severe pain. These lesions are chronic, lasting 
for months or years, and the cicatrix which eventually forms may be 
covered with telangiectases. Fortunately, these severe burns are now 
of rare occurrence. The majority of recorded cases occurred after long 
exposures for skiagraphic purposes. 

A chronic form of dermatitis occurs on the hands and sometimes on 
the face of .T-ray operators, which is attended by scaling, atrophy, oblit- 
eration of the normal lines of the skin, telangiectases, alopecia, and at 
times loss of the nails. Ulcers and hyperkeratoses, some of which 
developed later into epithelioma, have occurred, and occasionally a con- 
dition simulating scleroderma has been noted. 1 

Of great importance in estimating probable results are the facts that 
the reaction of the skin exposed to the ^r-rays occurs only after a period 
of delay, which may be prolonged for three weeks or more, and that 
the effects are cumulative. 

The Pathological Action of arrays has been studied both on man 
and in animals by several observers. Scholtz 2 concludes that : First, 
the rays cause a slow degeneration of the elements of the skin, in which 
the cells, not only of the epidermis and its appendages, but also those of 
the corium, may participate. This degeneration affects the nucleus as 
well as the protoplasm of the cell. The rays also induce, but to a much 
less extent, a degeneration of the fibrous elements, the collagen, elastin, 
and of the muscles. Second, when the cellular degeneration reaches a 
certain point an inflammatory reaction occurs, in which the blood-vessels 
become dilated and an extravasation of serum and leucocytes results. 
The latter then seem to act as phagocytes and to destroy completely 
the degenerated cells. MacLeod 3 adds that " the inflammatory reaction 
induced by .r-rays is peculiar in that it occurs in a tissue the vitality of 
whose various elements has already been impaired by the action of the 
rays, and in that it is associated with greater destructive changes than 
those produced by actinic rays, and is apt to lead to ulceration and 
necrosis, and is liable to be followed by an imperfect process of repair." 
An agent having such properties is obviously of great value, but not 
without danger in its application. 4 

The X-ray Apparatus. — Two forms of apparatus are in common 
use, one employing an induction-coil, the other a static machine. An 
electric current or storage batteries are essential when a coil is selected. 
Either apparatus will accomplish the desired end when properly 
managed. The popular idea that the static machine should be used for 
therapeutic purposes on account of its greater safety, is erroneous, as 

1 Jour. Cutan. Dis., 1903, xxi., p. 52. 

2 Archiv, 1902, lix., pp. 87 and 241 (abstr. in Brit. Jour. Derm., 1902, xix., p. 397). 

3 Brit. Jour. Derm., 1903, xv., p. 365 (with review of literature on pathological action 
of r-rays.) 

4 The treatment of x-ray dermatitis is considered with other forms of dermatitis. 



116 GENERAL THERAPEUTICS. 

serious damage has been wrought by its use. A coil having a double or 
a triple winding in the primary, which may be connected in parallel or 
in series, is efficient. It should furnish a spark-gap of the length of 
30 cm. Four varieties of interrupters are used : the turbine and the 
dip interrupters, in both of which mercury is used ; the Wehnelt (or 
electrolytic), and the vibratory interrupter ; each of the four possesses 
some advantage peculiar to itself. A voltmeter, ammeter, and tacho- 
meter indicate, respectively, voltage, amperage, and frequency of inter- 
ruptions. Lead plate, as a rule, is interposed between the tube and the 
skin in the vicinity of any lesion to be treated. The lead is placed 
between the tube and the patient, and should have an aperture of the 
size or slightly larger than the lesion to be treated through which the 
rays pass. Rontgen found that lead one-sixteenth of an inch thick was 
impervious to all rays. Practically, however, one-thirty-seeond of an 
inch is sufficiently thick. Aluminum screens, advised by Thompson, 1 
may be interposed, when treating deeper lesions, to intercept some of 
the rays which are absorbed superficially and which induce early derma- 
titis. The elimination of these rays allows the treatment to be pur- 
sued for a longer period without damage to the superficial tissues. 

Technique.— A reasonably safe technique was early devised by 
Schiff and Freund, as follows : The coil should furnish a spark-gap of 
30 cm. A primary current of 12 volts and 1^- amperes is advised, 
with interruptions of 600 to 1000 per minute. The tube should be 
placed 15 cm. distant from the surface treated, gradually reducing the 
distance to 5 cm. The time of treatment in the beginning should be 
five, this to be increased gradually to fifteen, minutes. Three prelimi- 
nary exposures of five minutes each, given daily, with the tube at a 
distance of 15 cm., are first to be employed. If, after an interval of 
three weeks, no unusual reaction occurs, treatment is resumed and pur- 
sued. As there are no means of measuring exactly the quantity of radi- 
ation from a given tube, and as the reaction in each individual case must 
be the chief guide, a perfect technique cannot be outlined. (For details 
as to duration and number of exposures, distance of the tube, etc., con- 
sult the chapters devoted to the diseases in which this treatment is 
recommended.) Preliminary exposures with a view to testing the sus- 
ceptibility of the patient should never be neglected, especially in the 
treatment of such disorders as acne and hypertrichosis. The difference 
in susceptibility of different patients to the rays is not only demonstra- 
ble, but in certain cases, amounts to a dangerous idiosvncrasy. 

Tubes. — The greatest problem in radiotherapy is furnished by the 
tube. Successful treatment depends much on the ability of the operator 
to recognize, to a degree at least, the condition of the tube employed. 
Tubes are designated as "hard" or " soft.' 7 A hard tube is one in 
which, the vacuum being more perfect, there is a marked resistance to 
the passage of the electric current ; its rays have penetrating qualities, 
contain fewer of the rays absorbed superficially, and consequently affect 
the skin only after a number of exposures. A soft tube has the reverse 
effect. Its vacuum is relatively low ; it offers but little resistance to 
the passage of the electric current ; the rays produced in it are largely 
1 Boston Med. and Surg. Jour., 1896, cxxxv., p. 610. 



EXTERNAL TREATMENT. 117 

absorbed by the superficial tissues ; and it readily produces dermatitis. 
The shadow-picture on the fluoroscopic screen produced by arrays from 
a hard tube shows but little contrast between the flesh and bones of the 
hand ; while with a soft tube the contrast, for obvious reasons, is con- 
spicuous. A newer tube emits more .r-rays than an older tube. Tubes 
become hard by use, and if not fitted w T ith a regulating device, become 
inefficient. Rest softens a hard tube to some extent. The focus of the 
cathode rays need not be small for therapeutic work ; for fluoroscopy and 
skiagraphy this is essential. A tube having a regulating device of some 
sort is preferable, as it can then be softened at will. 

It follows that in the treatment of superficial cutaneous diseases soft, 
or moderately soft, tubes are preferable, even though they may pro- 
duce dermatitis if used sufficiently. It is this quality that gives 
them their efficiency. With such tubes a large amount of treatment is 
never necessary, and the reaction should be anticipated by suspending 
treatment before its appearance. By careful regulation of the other 
factors, such as the intensity of the light, etc., best results may be 
obtained. In epithelioma usually a moderately hard tube is advisable, 
the quality depending largely on the depth of the lesion and the quan- 
tity of rays usually necessary for its removal. Other elements equal, 
the intensity of the rays varies directly with the strength of the primary 
current (Rontgen), and the effect varies inversely as the square of the dis- 
tance of the tube from the surface exposed. In epithelioma radio- 
therapy possesses the advantage of being a painless method of treatment. 
As pathological cells are affected and destroyed with a smaller amount 
of #-rays than normal cells or normal connective tissue, it follows that 
good cosmetic results may be obtained when the quantity of rays applied 
is sufficient to destroy the diseased cells without injury to other 
structures. 

Phototherapy. — Since 1896, when Finsen published his first report 
on the treatment of lupus vulgaris with concentrated chemical rays of 
light, the therapeutic value of light has been studied both clinically 
and experimentally in the laboratory by many observers, and the litera- 
ture of the subject has become extensive. 1 

The bactericidal properties of light were demonstrated first by 
Downes and Blunt in 1877, and since then by many other observers. 
The fact is now well established that the chemical rays of light, if con- 
centrated and their action sufficiently prolonged, are capable of destroy- 
ing the majority of pathogenic bacteria, though the resisting power of 
different micro-organisms differs considerably. The experiments of 
Finsen, Bang, Bie, Freund, Stroebel, Busch, Jansen, and others have 
demonstrated : (1) That of all parts of the spectrum the ultra-violet v rays 
are the most highly bactericidal, and are also most stimulating to plant 
and animal cells, these properties gradually diminishing in power 

1 For bibliography, see Mittheilungen aus Finsen's Lysinstitut. Nos. 1-4 (German 
translations, Leipzig and Jena, 1900-4) ; Leredde et Pautrier, Annales, 1902, 3 s., ill., 
p. 341, and Phototherapie et Photobiologie (monograph of 267 pp.), Paris, 1903; 
Freund, Grundriss der Gesammten Padiotherapie (monograph of 423 pp.) , Berlin and 
Vienna, 1903; Moller, Bibliotheca medica, Abt. D 11 (monograph of 142 pp.) ; Hyde, 
Montgomery and Ormsbv, Jour. Amer. Med. Assoc, 1903, xl., p. 1 ; and Montgomery, 
Jour. Cutan. Dis., 1903, xxi., p. 529. 



118 GENERAL THERAPEUTICS. 

toward the red end of the spectrum, where they are comparatively 
slight. (2) The power to penetrate tissue is greatest at a certain point 
in the ultra-red part of the spectrum, and diminishes in both direc- 
tions, the ultra-violet rays being absorbed for the most part by a 
thin layer of glass or by the uppermost layer of the epidermis, and 
unable to penetrate the skin more than a millimeter. (3) The effective 
rays in the treatment of skin diseases are, therefore, the visible blue 
and violet, and the immediately adjacent ultra-violet rays, since these 
are both bactericidal and stimulating to cells and have some power of 
penetration. Jansen has shown that by prolonged action (seventy-five 
minutes) of the light as employed at the Finsen Institute in Copen- 
hagen, bacteria may be destroyed, in tissue exsanguinated by pressure, 
at a depth of 1.5 mm., and their growth retarded at a depth of 4 mm. 
beneath the skin. The stimulating effects of the light probably pene- 
trate somewhat deeper. 

Though the earlier studies of Widmark, Hammer, and Unna on 
the production of dermatitis and pigmentation by the violet rays ; of 
Graber, DuBois, Bert, and Lubbock on the influence of violet rays on 
the activities of certain animals ; the broader and more fundamental re- 
searches in this field of v. Sachs and Jacques Loeb ; and the subse- 
quent demonstrations of Friedlander, paved the way for the later 
investigations of light-therapy, to Finsen belongs the credit of having 
first made practical and successful use of light in the treatment of 
disease. 

Phototherapy as employed by Finsen and his followers is based 
on the principle of concentrating a large number of chemical rays of 
light on a small area, at the same time excluding the heat rays as far 
as possible. A few seconds' exposure to such concentrated light may 
produce a superficial erythema, but exsanguination of the area to be 
treated and long exposures (usually one hour) are necessary to secure 
deep penetration of the light and to produce an acute inflammatory reac- 
tion at the tissues. Sunlight, which Finsen employed at first, and 
which still is used to some extent by him in summer, is too uncertain 
in its availability for general use, and is apparently less effective than a 
strong electric arc light. 

The light from a powerful electric arc is condensed by means of a 
series of lenses so enclosed in a metal tube as to form chambers which 
are filled with distilled water to absorb the heat rays. The lenses are 
made of rock crystal, as glass absorbs too large a proportion of the 
ultra-violet rays. The collecting lenses are 7 cm. in diameter (larger 
sizes being difficult to obtain and very expensive) and the rays are 
brought to a focus about six or seven inches from the lower end 
of the tube. Surrounding one of the divisions containing water is 
an outer jacket through which ordinary cold water circulates, thus 
preventing overheating of the apparatus. In Finsen's original apparatus 
he employed an arc light of from 60 to 80 amperes and about 70 volts. 
In each quadrant of the circle around the lamp was placed a system 
of condensers, thus permitting the treatment of four patients with one 
light. This apparatus is suitable for institutions where numbers of 
patients are to be treated daily. A smaller lamp has been devised by 



EXTERNAL TREATMENT. 119 

Finsen and Reyn in which they use practically the same system of con- 
densers, but by employing one lens of shorter focal distance and by so 
directing the arc that the strongest rays fall directly on the first lens, 
20 amperes and 55 volts give results equal in every way to those 
obtained by the larger apparatus. The lamp is mounted on an adjust- 
able stand, and is much cheaper to instal and maintain than the original 
apparatus, and more suitable for all use outside of large institutions. 

In treating a given area, the patient should be so placed that the 
light falls perpendicularly upon the surface to be treated, which is 
brought near enough to the lamp so that the rays are concentrated in a 
circle from one-half to one inch in diameter. Throughout the seance 
this position must be accurately maintained and the area under treat- 
ment must be exsanguinated. The tissues are kept bloodless by means 
of constant pressure applied by an attendant with specially prepared 
compressors. These are composed of two quartz lenses so held 
together by a metal rim as to leave between them a narrow space through 
which cold water 1 constantly circulates, to prevent the heating of the 
lens. According to the contour and location of the area to be treated, 
the lens which comes in contact with the surface may be plane, slightly 
concave, or convex in varying degrees. For certain sites, as, for ex- 
ample, the inner canthus of the eye, compressors of special shape and 
size are made. Though in Finsen's Institute these compressors are 
usually held in place by an attendant, who thus must give her whole 
time to the treatment of one patient, they are made so that they can 
be fastened in place by means of a tape or elastic bands. We find 
that by properly adjusting these bands and by carefully placing the 
patient, frequently with the aid of a photographer's head-rest, so that 
the part to be treated is well supported, equally good results are 
obtained and at much less expense than when each patient requires the 
constant attention of a nurse or attendant. 

The water in the compartments between the condensing lenses 
absorbs most of the heat (nearly all of the ultra-red) rays, but trans- 
mits not only the ultra-violet rays, but also nearly all of the visible 
spectrum. Consequently if the light be too concentrated the heat 
may be sufficient not only to cause pain, but also to burn the skin — an 
effect that should be avoided as it means the destruction of some 
normal tissue and the consequent production of larger and deeper 
scars. The amount of concentration which different patients and 
different conditions will tolerate varies considerably. It is desirable 
to use the rays as strong as possible without burning. 

The frequency of the applications and the duration of each vary for 
different conditions and for different individuals. For superficial 
lesions which can be perfectly exsanguinated, half hour exposures are 
often sufficient. For deep-seated lesions from one to two hour seances 
may be necessary. On each area the treatment is repeated, when neces- 
sary, as soon as the reaction has subsided, which it does usually in 
from one to two weeks. 

Following each treatment an inflammatory reaction occurs in from 
six to twenty-four hours, varying in degree according to the intensity 

1 The space is so narrow that distilled water is not necessary. 



120 GENERAL THERAPEUTICS. 

and duration of the treatment, from a simple erythema to a vesicular 
or bullous dermatitis which is sharply limited to the area to which the 
light was applied, though when the reaction extends at all below the 
surface there is a surrounding narrow zone of oedema. The outline 
of the area of reaction thus affords a ready test of the accuracy with 
which the compressor and light were kept in position during the treat- 
ment. The vesicles and bullae dry and form crusts which ultimately 
fall leaving only the new forming epidermis. The process requires as 
a rule from eight to twelve days. The inflammation produced by the 
light causes no necrosis and no destruction of normal tissue, all of 
which is conserved. Hence the inconspicuous scars produced and the 
value of the treatment from a cosmetic standpoint. Moreover, the 
light may be applied freely not only to the diseased area, but also to 
the apparently normal tissue surrounding it, thus insuring destruction 
of advancing pathological processes which cannot be recognized clini- 
cally. In the normal skin, the reaction on subsiding is followed 
usually by more or less pigmentation, which usually disappears in 
another ten days or two weeks. Another effect of the light upon 
normal skin is to produce a slight dilatation of the superficial vessels 
which may persist for six months or more. The sole clinical mani- 
festation of this condition is the readiness with which slight external 
irritation produces an erythema of the part. 

The success of the treatment depends largely upon the care with 
which the technique is carried out in all its details. It is especially 
important that the lenses, both of the condenser systems and of the 
compressors, be kept absolutely clean. The latter should be cleansed 
with antiseptic solutions after each treatment. The distilled water 
in the chambers of the condensers should be changed often enough to 
keep it free from particles of dust or dirt, and air bubbles should not 
be allowed to collect on the lenses. 

Though the light treatment has been used most successfully in the 
treatment of lupus vulgaris and other forms of cutaneous tuberculosis, 
it is of value in the treatment also of lupus erythematosus, alopecia 
areata, rosacea, vascular nsevi, and some chronic inflammatory cutane- 
ous diseases of circumscribed areas. The special technique appropriate 
lor each of these conditions is considered with the general treatment of 
each. Phototherapy is limited in its applicability by the fact that the 
rays can penetrate exsanguinated tissue only, and this but to a limited 
depth. The area treated at one time is small, averaging less than an 
inch in diameter. Consequently when the disorder to be treated is 
extensive the method as now applied is both tedious and expensive. 

Numerous lamps have been invented in the effort to produce one 
with which more rapid results can be obtained and with less expense, 
They may roughly be divided into two classes : 

In the first class, of which the Lortet-Genoud and the London 
Hospital lamps are the best-known examples, the source of light can 
be brought Avithin two inches of the region to be treated, the need of a 
condenser being thus done away with. The patient is protected from 
the light by a hollow shield in the centre of which are two rock crystal 
lenses, front and back, between which cold water constantly circulates 






EXTERNAL TREATMENT. 121 

and absorbs the heat rays. The part to be treated is exsanguinated by 
pressing it firmly on the face of the front lens. An arc light is 
employed having carbon electrodes, an amperage of 10 or 12, and a 
voltage of 55. These lamps are in some respects more convenient and 
less expensive to use than even the Finsen-Reyn lamp, and give good 
results in superficial lesions, but the light from them has not the pene- 
trating power of that given by lamps which have a series of condensers 
and employ arc lights with higher amperage. 

The second class of lamps, of which there are many, are constructed 
with the. aim of furnishing ultra-violet rays in quantity. For this pur- 
pose iron or other metal electrodes, or the high-tension condenser spark, 
have been used. These lamps are small, convenient, of low amperage 
(1 to 4), and therefore less expensive to instal and to maintain. Some 
of them are powerful in destroying surface cultures of bacteria and in 
exciting inflammation on the surface of the skin. As they depend for 
these effects upon the ultra-violet rays which are absorbed by the upper- 
most layers of the epidermis, they have no influence upon lesions 
situated at all deeply in the skin. 

The Becquerel Rays. 1 — In the year 1896 Becquerel discovered 
the radiating power of uranium and some of its salts. Later Curies 
separated both radium and polonium from pitchblende. From radium 
and its compounds there are given off at least three varieties of rays. 
One variety, apparently peculiar to these radioactive substances, are 
bactericidal and have very slight power of penetrating tissue. The 
other two varieties of rays have been likened to the cathode and .T-rays 
respectively. Observers, however, do not agree fully as to the exact 
nature and relation of these different forms of radiation. 

The effects of radium upon tissue have not been studied suffi- 
ciently to warrant definite conclusions, but they seem to be similar in 
many respects to those of the a--rays. Deep-seated dermatitis and 
ulceration have resulted from prolonged action of the salts of radium 
on the skin. London found that in mice radium rays of sufficient 
strength produced general torpor and death. He has shown also that 
persons who are almost blind can perceive light when radium is brought 
near their eyes. It is evidently an agent that should be used with the 
greatest caution until its properties are better understood and until 
some method is found of accurately determining the exact radiating 
power of each preparation used for therapeutic purposes. From the 
results obtained in a few cases of lupus erythematosus, epithelioma, 
melanosarcoma, and other morbid conditions, it is probable that when 
substances possessing a definite radioactive value can be obtained at a 
reasonable price, radium and its salts may be utilized in the practical 
treatment of those superficial cutaneous diseases for which the :r-rays 
and the Finsen light are now employed. 

1 For review of the subject, and bibliography, see: Turner, Brit. Med. Jour., 1903, 
ii., p. 1523; Maclntvre, Ibid., 1903, ii., p. 1524; Jumon, Jour. Mai. cutan., 1903, xv., 
p. 854. 



VIII. CLASSIFICATION 



The numerous attempts which have been made to classify diseases 
of the skin according to their nature and relations have been in response 
to the generally recognized demand for a systematic arrangement of all 
scientific facts. As regards dermatology, not only have these attempts 
been numerous and based upon different principles, but the results which 
they have accomplished have also been in the highest degree divergent. 
No classification yet devised has secured general acceptance. While it 
is certain that no one system of classification has been perfect, and that 
each lias exhibited defects, it is equally true that of the large number 
each has possessed some merit of its own. No perfectly satisfactory 
classification of cutaneous diseases can be made until the knowledge of 
diseases of the skin has been greatly enlarged. 

One of the most acceptable of the systems thus far proposed is that 
of Hebra. In it cutaneous disorders are arranged in the following 
nine classes : 

Class 1. Disorders of secretion. 

Class 2. Hyperemias. 

Class 3. Exudations. 

Class 4. Hemorrhages. 

Class 5. Hypertrophies. 

Class 6. Atrophies. 

Class 7. NeAv Growths. 

Class 8. Neuroses. 

Class 9. Parasites. 
Since this classification was devised by Hebra none has been pro- 
posed which compares in ingenuity with the arrangement made by 
Auspitz. The principle of this classification is to place together those 
diseases and groups of diseases which present a clinical unity, the general 
pathological process being the predominant characteristic for selection ; 
individual characteristics, such as symptoms, localization, anatomical 
peculiarities, etc., being only brought thus predominantly forward when 
coinciding with the real nature of the class, the group, or the skin- 
disease in question. 1 Auspitz' s nine classes are : 

1. Simple Inflammatory Dermatoses; 2. Angioneurotic Dermatoses; 
3. Neurotic Dermatoses ; 4. Stasic Dermatoses ; 5. Hemorrhagic Der- 
matoses ; 6. Idioneuroses ; 7. Epidermidoses ; 8. Chorioblastoses ; 
9. Derm atomy coses. 

Under these classes, by the aid of divisions and subdivisions, an 
elaborate scheme is presented which embraces not only all cutaneous 
1 System d. Hautkrankheiten. Wien, 1881. 
122 






CLASSIFICA TION. 1 23 

diseases, but also all pathological processes recognized in the skin. 
The mere presentation of this system has been followed by an advance 
in the nosology of cutaneous medicine more satisfactory than any since 
the contributions to this subject by Hebra. 

Auspitz's classification, however, is open to various objections on the 
part of the student of dermatology. It is elaborated to the extent of 
placing the names of some diseases in more than one family, and hence 
is confusing to the beginner. It is better adapted to the needs of the 
expert than of the student, for it introduces to the study rather of 
morbid processes in the skin than of the complexus of those processes 
which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, or 
pathological ; whether it be based on the processes actually occurring 
in the skin, or on those deeper factors and forces which operate cen- 
trifugally upon the skin, and on which that organ depends for all its 
functions and even its existence ; whether it proceed etiologically from 
causes which are immediate or those which are remote, it is easy to see 
that, as knowledge in each of these directions enlarges, the exact position 
of any one disease in any given classification must be rendered insecure. 
Never was this observation more suggestive than at this day, when the 
pathogeny of numerous skin-disorders is revealed in the light thrown on 
the subject by the discovery of hitherto unknown inferior organisms. 

Indeed, to this last cause, awakening grave doubts as to the precision 
of much that w T as once esteemed fact, may be attributed the declining 
interest in the general subject of classification of diseases of the skin. 
The solution of its problems has practically been deferred by common 
consent to a date when the questions thus suggested can more satisfac- 
torily be answered. Several recent writers have contented themselves 
with an alphabetical indexing of the names of skin-diseases as an order 
useful simply for reference. 

The arrangement of titles of diseases of the skin in this treatise is 
a modification of the scheme first proposed by Hebra on the lines recog- 
nized by the American Dermatological Association in its classification 
adopted in 1884. In the successive editions of this work which have 
appeared since this classification was first accepted, changes from time 
to time have been made which were rendered necessary by the advance- 
ments of science. As the arrangement stands to-day it should be 
regarded as a mode of grouping diseases for the convenience of the 
student rather than as an attempt at a scientific classification of diseases 
of the skin. 



DISEASES OF THE SKIN. 



CLASS I. 
DISORDERS OF THE GLANDS. 



In this class of disorders are grouped the functional affections of the 
sweat-glands, or coil-glands, the sweat-pores, and the sebaceous glands. 
These disorders may be betrayed in quantitative or in qualitative 
changes in the secretion, or in retention of the latter in the whole or 
in a part of the secretory apparatus. When a disease of the skin 
ceases to be purely functional in type, and is accompanied by an exud- 
ative process, glandular or periglandular in situation, such disease 
is properly classed with another group of affections. With a view, 
however, to convenience of arrangement there have been placed in 
this class a few dermatoses which cannot be regarded as strictly func- 
tional affections. 

1. DISORDERS OF THE SWEAT-GLANDS. 

HYPERIDROSIS. 1 

(Gr. V7rep f in excess ; vdup, water.) 

(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, 
Hyperhidrosis. Fr., Hyperidrose.; 

Hyperidrosis is an exaggerated quantitative effusion of sweat, local- 
ized or generalized, moderate or severe, acute or chronic, persistent or 
relapsing, the secretion accumulating in visible drops upon the surface 
of the skin. 

Symptoms. — This condition may be physiological, as the result of 
active exertion in a medium of high temperature ; or it may be patho- 
logical in character, and in the latter case be either general or partial. 

General sweating to a pathological extent chiefly occurs in the obese, 
but also in those who are the subjects of constitutional disease (phthisis, 
the various febrile disorders, etc.). It is the fertile source of the vari- 
ous forms of intertrigo, sudamina, and miliaria. Local hyperidrosis 
is the exaggerated quantitative effusion of sweat limited to certain defi- 

1 For bibliography, see Torok, Mracek's, Handbueh Bd. i., pp. 388-403. 

125 



126 



DISORDERS OF THE GLANDS. 



nite portions of the skin, as the palms, the soles, the dorsa of the 
hands and feet, the interdigital spaces, the genitals, the axillae, and the 
temples. In such cases the secretion occurs moderately or greatly in 
excess, varying in this respect somewhat in different degrees of tem- 
perature and in rapidity of the circulation ; it is occasionally, but not 
commonly, accompanied by fetor. It may involve one or both sides 
of the body, being generally symmetrical upon the extremities and 
asymmetrical upon portions of the face. In rare and isolated cases it 
has proved fatal. 

The localized hyperidroses may be unilateral or affect exclusively 
the upper or the lower segment of the body. Where the axillary and 
genital regions are involved, there is usually coincident bromidrosis. 
The topical expression of this disorder may be studied in the hands, 
which are continually moistened, clammy, or dripping with fluid within 
a brief time after the most careful drying of the parts. The sweat is 
commonly cold to the touch of another. In the case of a woman, 
the instincts of whose sex prompt her to take such precautions, the 
dress is constantly protected from contact w T ith the macerated palms 
by a handkerchief or similar article which is always in readiness. The 
disadvantages thus arising in individuals of both sexes who are en- 
gaged as tradespeople, artists, hand-workers, etc., are obvious. In 
women of social position no small complaint is made of the disagree- 
able result produced after wearing kid gloves for even a short time, 
the material of which is soon soiled by its complete saturation with the 
secretion from the skin. 

With and without this local excess occurs the hyperidrosis of the 
feet, aggravated by the mechanical force of gravity and the need of 
constant covering. The stockings and the leather of the boots, shoes, 
or gaiters are saturated with the secretion, and rapidly become subject 
to chemical alteration. There is usually an offensive odor of the re- 
gion, originating partly in the primary fetor of the secretions them- 
selves, and partly in the subsequent chemical decomposition of the 
latter, rapidly progressing under the influence of the soiled and often 
stinking investments of the feet. 

The integument, constantly macerated, may become both painful 
and tender ; occasionally there is vesiculation or exfoliation of patches 
of sodden epidermis. When the genitals are involved, especially in 
men, erythema and intertrigo are the frequent results. 

Etiology. — The disease is frequently recognized in persons suf- 
fering from an habitually rapid or slow pulse or from organic cardiac 
disease ; it may result from adynamia due to any cause ; in rare cases 
it is congenital. In other instances it is associated in one person with 
disorders not apparently related to it. In the case of a hospital patient 
recently examined, a woman, twenty-four years of age, was affected 
with severe tylosis of the feet, from which were exfoliated extensive 
lamellated casts of the soles. She had also hyperidrosis of the hands. 

In no portion of the nervous system has a localized centre for excito- 
sudoral or inhibitory effects been recognized. Traumatisms, gliomata, 
gummata, scleroses, and other lesions affecting the cerebrum, medulla, 
cord, ganglia, and trunks of the sympathetic nervous system have been 



H YPERIDR OSIS. 127 

followed by local hyperidrosis, but they have all repeatedly failed to 
induce such morbid sudoral symptoms, while a fit of anger or sudden 
fright has been as conspicuously effective as any. Both local and 
general hyperidrosis may occur in general paralysis. 1 In short, the pre- 
dominant influence of the nervous system in an etiological sense must 
be admitted here as in physiological sweating, and to the sympathetic 
branches of that system must be assigned the greater influence for most 
cases. A paralysis or paresis of the sympathetic is held to explain the 
occasional coincidence of pulmonary and cardiac disorders with either 
general or partial excessive sweating. Compression of the sympathetic 
by adenomata, aneurisms, carcinomata, etc., has been followed by 
marked symptoms of this disorder. The disease is encountered in 
individuals of both sexes, and in all ages and degrees of general health, 
as also in those who are and those who are not cleanly. The disease is un- 
questionably produced in certain individuals by the use of one or more of 
the narcotico-stimulants (alcohol, tobacco, opium and its alkaloids, coffee 
and tea). There is reason to believe that the facial asymmetrical hyperi- 
droses associated with migraine, neuralgias, hemicrania, etc., are etio- 
logically and pathologically distinct from the similar symmetrical affec- 
tions of the hands and feet. The last-named disorders certainly occur 
with conspicuous frequency in young women who are the subjects of 
hysteria, chloroanaemia, some form of dysmenorrhea, or cardiac trouble. 

Pathology. — Robinson, who examined a number of sections from 
the palm of the hand, failed to detect any abnormal feature either in 
the glands or in the epithelium. The disorder is to be regarded as 
purely functional ; and any anatomical changes in the coil-glands 
or "the sweat-pores are probably accidents of such derangement of 
function. 

Treatment. — When universal, hyperidrosis is to be treated internally 
by the aid of such remedies as are indicated by the general condition 
of the patient, and especially by the condition of the heart. The 
various ferruginous tonics, mineral acids, arsenic, strychnine, stroph- 
cinthus, quinine (the latter particularly when, as is often the case, a 
malarial affection is responsible for the disorder), and ergot, with both 
belladonna and atropine, are all of unquestioned value. Crocker 
administers sulphur internally. Even though but temporarily service- 
able, belladonna and atropine are well used at the outset of most cases. 
Aconite, jaborandi and pilocarpine, white agaric, (agaricin is recom- 
mended in doses of ^ grain (0.011), repeated as required), carbolic and 
salicylic acids may be named as in the second rank. Meat should 
always be largely eliminated from the dietary. The narcotico-stimu- 
lants as a rule should be excluded. 

External treatment, which is often promptly efficacious, should not 
be neglected in any case. The simplest method is by wiping, not wash- 
ing, the skin-surface until it is dry, and applying a dusting-powder, such 
as lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, chloral 
hydrate (1 part to 5 or 6 of starch), or starch. Alternately with either 
of these, or in lieu of them, baths or lotions may be employed, aqueous 

1 Cf. De Montzel, La Presse med., 1903, xi., p. 749 (six cases, with review of 
subject). 



128 DISORDERS OF THE GLANDS. 

or alcoholic, and medicated with corrosive sublimate, formalin (1 to 5 
per cent, solution), tannic acid, ferrous sulphate, naphtol (Kaposi), tur- 
pentine, zinc sulphate, alum, potassium permanganate, or common 
salt. Daily sponging of the affected surface with weak solutions of 
formalin (1 to 6 per cent.) will remove the odor, and will in most 
cases greatly diminish the amount of perspiration, but on suspension 
of the treatment the condition usually returns. Fox 1 advises a lotion 
containing 1 part of quinine to 100 of alcohol. Van Harlingen 
recommends the use of juniper-tar or carbolic-acid soap with the 
bath as alone sufficient to relieve some cases. Grosse 2 praises highly 
tannoform, either in powder (1 part to 2 of talcum) or as a 25 per 
cent, plaster. 

For hyperidrosis of the feet the treatment by the method of Hebra 
has deservedly high repute. It consists in neatly and completely 
enveloping the entire foot, the toes separately, after thorough washing 
and drying, in strips of cotton-cloth over which is spread to the thick- 
ness of a common knife-blade the unguentum diachyli albi. This 
unguent is made by boiling 1 part of the best litharge with about 
4 parts of pure olive-oil, to which a little water is added while the 
materials are stirred together over a slow fire. The parts are well 
bandaged, and the patient either remains subsequently at rest or pur- 
sues his vocation, wearing over the feet shoes and stockings which 
have not previously been worn. In twenty-four hours the feet are 
redressed without washing, after dry rubbing with charpie and a dust- 
ing-powder. This treatment is repeated daily for from ten to tAventy 
days, after which a dusting-powder (boric acid) may be substituted 
for the local dressing. There occurs a parchment-like desquamation 
of the epidermis in thick, yellowish-brown lamellae, beneath which is 
formed a new and at first tender but apparently normal epidermis. 
When the latter has lost its tenderness the feet are for the first time 
washed with water. In case of failure the routine of treatment 
is repeated as often as requisite. It is scarcely necessary to add 
that no ill effects are known to have resulted from the therapeutic 
measures adopted in checking a local hyperidrosis. For the dia- 
chylon salve there may be substituted tar, ichtbyol, or naphtol 
ointment. 

Gerdeok 3 makes three applications to the soles, at intervals of about 
eight hours, of the strongest solutions of formalin the skin of the indi- 
vidual will bear. In some instances full strength is well tolerated. A 
few drops are put in the shoes, the influence on the leather being pre- 
servative and not destructive. Relief follows for several weeks, when 
the treatment may be repeated. 

Fredericq employs finely pulverized tartaric acid, applied at first 
with some caution, and always in small quantities. Stewart first bathes 
the feet in hot water and then soaks them for a few moments, once 
only, in a solution of potassium permanganate, 4 to 6 grains to the 
ounce (0.266-0.4 to 32.), after which the plaster selected for use may 

1 Jour. Cutan. Dis., 1885, iii., p. 24. 

2 Klin, therap. Wchnschrft., 1889, Nos. 16 and 17. 

3 La Kiforma Medica, 1898, No. 38. 



SUDAMEN. 129 

be applied as directed above. Legoux orders pediluvia of tar- water 
twice daily for three days, followed by painting of the feet with a 
solution of iron perchloride. Morrow 1 recommends foot-baths in the 
extract of pinus Canadensis, followed by the application of boric acid, 
or of salicylic acid mixed with lycopodium. Stel wagon 2 reports relief 
after exposure to the x-yslj. 

Prognosis. — The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
may recur, may promptly be amenable to treatment, or may prove 
obstinate to all therapy. Myrtle 3 reports the case of a male patient, 
seventy-seven years old, who sweated to death after repeated recur- 
rences of severe hyperidrosis, and after temporary relief from the use 
of Fowler's solution. 

SUDAMEN. 4 

(Lat. sudor, sweat.) 

(Miliaria Crystallina. Ger., Friesel; Fr., Miliaire 

CRYSTALLINE.) 

Symptoms. — In this disorder the lesions are thickly agglomerated, 
but discrete, transitory, and translucent, pin-point-sized vesicles, resem- 
bling dew-drops or seed-pearls, upon the surface of the skin, often requir- 
ing the touch to define their real character. These lesions are usually 
limited to certain regions of the body, as the neck, chest, or other parts 
of the trunk, but rather more generally develop upon the front and sides 
of the belly and in the iliac regions, though they may occur upon any 
part. Their course is rapid, both in evolution and involution, and their 
sequelae are exceedingly delicate desquamative flakes, the thin roof-wall, 
which originally covered the sweat-drops, having been lifted from the 
superficial stratum of the horny layer of the epidermis. They contain 
each a droplet of sweat, which is removed by evaporation. They are 
usually preceded by an attack of pruritus, and may follow the hyperi- 
drosis of systemic debility, enteric and continued fevers, phthisis, in- 
flammatory rheumatism, pneumonia, and other asthenic conditions. 
They may also result from violent exercise, the elevated temperature 
of the summer season, flannel underclothing, vapor-baths, and the 
application of wet hot cloths to the surface of the skin. 

The lesions are the result of the accumulation of sweat in high tem- 
peratures of the external surface of the body or of the medium by 
which the body is surrounded, and usually in states of adynamia. The 
sweat accumulates between the most superficial layers of the stratum 
corneum. Sudamina may hence occur at all ages and in both sexes. 

Three forms of sudamina have been described : (a) sudamina alba ; 
(6) sudamina rubra ; and (c) sudamina crystallina. The last named is 
the only form to which the term sudamen is properly applied, since it 

1 See his resume of this subject in Jour. Cutan. Dis., 1887, v., pp. 68, 113. 

2 Diseases of the Skin, p. 982. 

3 Medical Press, February 25, 1886. 

4 For bibliography, see Torok, Mracek's Handbuch, Bd. i., pp. 418-422. 
9 



130 DISORDERS OF THE GLANDS. 

alone of the three designates a purely functional derangement of the 
sweat-secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to the lesions 
occurring where there is maceration of the vesicular wall and when 
the contents become opalescent. This form is rare. The second term, 
sudamina rubra (miliaria rubra, miliaria papulosa, lichen tropicus, 
" prickly heat "), is applied to inflammatory lesions which may accom- 
pany profuse sweating. These lesions are numerous acuminate pin- 
point- to pin-head-sized vesicles surrounded by a reddish halo, or 
papules of the same dimensions, or the two lesions commingled, almost 
invariably accompanied by hyperidrosis, though the latter may be 
absent in high temperatures. Areas of diffuse redness may develop 
where few of the elements of the eruption are visible. The marked 
tingling, pricking, and burning sensations by which they are accom- 
panied are often in the highest degree distressing, and may solicit rub- 
bing of the affected part, though the scratching elicited by severe pru- 
ritus is not common. Minute crusts may form after vesicular rupture. 
The attack may be mild or severe, and may last for a few days or for 
a few weeks or months, the result of continuous aggravation or of the 
production of new crops of lesions after each recurrence of the cause. 
The affection is not rarely complicated in obese individuals by all 
varieties of intertrigo and eczema. Sudamina crystallina are, however, 
the sole lesions which may properly be referred to this class of affec- 
tions. These vesicles are always free from inflammatory symptoms, 
presenting a limpid, dewdrop-like aspect that is characteristic. 

Etiology. — The disease is induced by excessive sweating, often in 
consequence of an elevated temperature ; also, however, as a result of 
a systemic asthenia, as indicated above. The vesicles may occur as 
symptoms of the death-agony. 

Pathology. — Robinson reports that the contents of the vesicles are 
pure sweat without admixture of lymphoid corpuscles. The fluid col- 
lects between the laminae of the deeper part of the corneous layer. A 
rupture of the wall of the sweat-duct may occur, but there may be instead 
obliteration merely of the sweat-pore by a sudden effusion of watery 
fluids toward the epidermis, that pass with moderate pressure through 
the wall-less sides of the pore into the spaces between the epithelial 
cells, where a chamber is readily formed. Torok found the walls of 
the vesicle composed purely of the corneous layer with a sweat-pore 
opening at the lower border of the chamber. 

Diagnosis. — No difficulty can arise in making a diagnosis if the 
peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents ; all bullous lesions are larger, or are 
seated on an engorged base, or they lack the limpid clearness of the 
sudamen, because, however transparent the contents, they are mostly 
covered by a thicker and less transparent roof. The halo about the 
lesions of miliaria rubra, or their rosy-pink shade, will determine their 
character. In varicella the lesions are chambered. 

Treatment. — Only the simplest treatment is required. Alkaline 
and bran baths may be employed, of the temperature most grateful to 
the skin. Afterward the surface may be dusted with one or several of 






HYDROCYSTOMA. 131 

the dusting-powders, such as starch, lycopodium, or boric acid, named 
in the chapter on General Therapeutics. The internal treatment is 
that indicated by the condition of the patient. 

Strophulus (" Red Gum ") is a term still employed by a few Eng- 
lish writers to designate an eruption due to excessive sweating in the 
infant closely swaddled. Crocker states that it occurs frequently as a 
unilateral affection of the side most in contact with the mother's body. 

Miliary Fever ("Sweating Sickness" ; Fr. y Suette miliaire) 
is an epidemic disorder, accompanied by sweating and a cutaneous 
exanthem. Pineau l gives a description of the disease as it occurred 
in epidemic form on the island of Oleron, where of one thousand 
patients affected, between one hundred and fifty and two hundred 
perished. The eruption appeared in the form of hypersemic maculae, 
disappearing under pressure, after which there rapidly formed myriads 
of reddish or whitish, grouped, unequally sized, acuminate papules, 
rising from a whitish and macerated surface. Among these papules 
were interspersed lesions of sudamina. The region of the face was 
not spared, and the conjunctivae were occasionally affected. In the 
course of from two to four days pinhead- to bean-sized, varioliform 
but non-umbilicated pustules formed in the site of some of the papules, 
the contents of which disappeared by resorption, the final lesions pre- 
sented being large, flat, reddish papules, the skin of the face partic- 
ularly becoming reddened and swollen. In the course of from ten to 
twelve days general desquamation ensued, with extensive palmar and 
plantar losses. Relapses occurred in some cases with diffuse redness 
of the surface or with crops of reddish plaques, or yet again with the 
occurrence of furuncles. The sensations were those of myriads of 
needles thrust into the skin. 

The exanthem was accompanied in some cases by fever. In the 
fatal cases death resulted from exhaustion. 

Geber and other writers, however, believe that the lesions described 
are not peculiar to any special disease, and they deny the possibility of 
an independent miliary fever. 



HYDROCYSTOMA. 2 

(HlDROCYSTOMA, CYSTS OF THE CoiL-DUCT.) 

Hydrocystoma is a chronic non-inflammatory disorder characterized 
by the presence on the face of scattered, isolated, deep-seated, persistent, 
clear vesicles. Robinson 3 has published a report of his studies in this 
affection, which he first described in 1882. Reports of cases and 
studies of the disease have been made also by Hutchinson, Jackson, 
Jamieson, Rosenthal, Hallopeau, Tebel, 4 and others. 

1 Arch, gen, de med., Jan., 1882, p. 25. 

2 For complete bibliography, see Torok, Mracek's Handbuch, Bd. i., pp. 423-426. 

3 Jour. Cutan. Dis., 1893, xi., p. 293. 

4 Annales, 1903, s. iv., iv., p. 273. 



132 DISORDERS OF THE GLANDS. 

Symptoms. — The lesions are discrete or closely set, few or exceed- 
ingly numerous, tense, well-developed, clear, shining, rounded or oval, 
pinhead- to pea-sized vesicles, never inflammatory and never super- 
ficially seated — that is, never so near to the surface as the vesicles of 
miliaria — because the base of all hydrocystomata is to be found in the 
corium. They have no tendency to rupture spontaneouslyo The 
lesions are whitish in color, or when of greater age and size are dark 
bluish, especially at the periphery, some resembling boiled sago-grains. 
No signs of inflammation are present. They occur chiefly upon the 
face, especially the brow, cheeks, and nose, in symmetrical distribution, 
and may prevail for weeks or months, or disappear in cool weather. 
Occasionally a mild hyperemia becomes evident at the periphery of a 
single cyst. The contents are pellucid, never changing to a yellowish 
hue, and when uninjured resolve in time by desiccation, leaving a short- 
lived pigmentation. The contents of the vesicles are slightly acid. 
They are always accompanied by very free sweating. 

Etiology. — The disease occurs almost invariably in middle-aged 
women, more often in those engaged as laundresses who have been 
sweating freely over the washtub, the face being simultaneously ex- 
posed to warm vapor. There is usually aggravation of the disorder 
in summer, and either complete or partial relief in winter. Aggrava- 
tion has been noted at the time of the menstrual period. One of 
Hutchinson's patients exhibited lesions on a single side of the face only. 
Robinson reports a case occurring in a young man. The patients seen 
by us have been usually of the dispensary class, and were women who 
worked much over the washtub. Hyde and McEwen l have reported 
a typical case occurring in a woman past the menopause, where sweat- 
ing was one of the symptoms of exophthalmic goitre. 

Pathology. — The epidermis, hair-sacs, and sebaceous glands are 
in all parts normal, the papillary layers being involved only when 
the cyst approaches the upper part of the corium, where " a thin plate 
of flattened papillary body " is found above. Below, in places, the 
lumen of the sweat-duct is found enlarged and distended with liquid 
and a granular material. The enlargement in the duct begins above 
the coil of the gland, and usually in the lower part of the corium. 
There is some perivascular leucocytosis in progress here and there in 
the vicinity of the vessels, but this was not a marked feature in any 
one of the several sections examined by Robinson. The cavities of 
each duct were found lined with epithelial cells. 

Diagnosis. — The lesions of sudamen and pompholyx are readily 
distinguished by their superficial character and their situation, as they 
are rarely discovered upon the face. The vesicles of eczema are short 
lived and inflammatory. In adenoma of the sweat-glands the lesions 
are often painful and usually firmer and larger than in hydrocystoma. 

Treatment. — The lesions can be caused to disappear by puncturing 
each, thus permitting the escape of the imprisoned fluid. A weak 
spirit lotion may then be applied, and this may be followed by the 
application of dusting-powders, due care being had to avoid the effec- 
tive causes of the malady. 

1 Araer. Jour. Med. Sci., June, 1903, n. s., cxxv., p. 1000. 



ANWROSIS. 133 

GRANULOSIS RUBRA NASI. 

Under this title Jadassohn l has described a peculiar affection of the 
nose in children. Other cases, making about twenty in all, have been 
recorded since by Hermann, Pick, and MacLeod. 2 The disease is a 
chronic inflammation of the tip of the nose, and is characterized by a 
more or less sharply defined area of redness on which are scattered 
irregularly, without definite arrangement, pin-point- to pin-head-sized 
dark-red macules and papules, The lesions fade completely under 
pressure, being thus distinguished from small lupous nodules, which 
they resemble clinically. Interspersed among these lesions are beads 
of perspiration, and there is, in most instances, coincident hyperidrosis 
of the hands. The hyperidrosis of the diseased area is a striking 
feature, and may be present over the entire face. The disorder is 
limited usually to the tip and sides of the nose, but occurs also on the 
cheeks, upper lip, and eyebrows. Subjective sensations are wanting, 
or limited to a slight itching. The disease is chronic and does not 
yield easily to treatment. The patients have all been children, ranging 
in age between six months and sixteen years, the majority of whom 
were of feeble constitution and showed poor peripheral circulation. 

The histological changes are those of inflammation, situated for the 
most part about the coil-glands and in some instances also near the 
hair-follicles. There is dilatation of the blood-vessels and lymphatics 
of the corium, with an infiltration consisting of leucocytes, connective- 
tissue cells, a few plasma-cells, and occasional mast-cells. In one case 
only, that reported by Pick, was there inflammation of the sweat- 
glands. 

The objective symptoms are so characteristic that the diagnosis is 
not difficult, though it might be confused with atypical forms of hydro- 
cystoma. 

Treatment apparently has little effect on the disorder, save that of 
temporarily diminishing the redness and number of papules. It is 
probable that the disease disappears spontaneously with maturity of 
the patient. 

ANIDROSIS. 

(Gr. «, privative; vdup, water.) 

(Anhidrosis. Ger. and Fr., Anidrose.) 

This name is applied to those morbid conditions in which no sweat 
is secreted from the surface of the body. Hypohidrosis i a term more 
exactly used to designate a relative, general or partial decrease in the 
quantity of the sudoral fluid. The former term, however, often is used 
to indicate the latter. 

Complete anidrosis occurs only when the sudoral apparatus has been 
involved in destructive or other changes in the skin (scars, atrophy, etc.). 

Diminution in the quantity of sweat excreted, or its complete sup- 

1 Archiv, 1901, lviii., p. 145. 

2 Brit. Jour. Derm.., 1903, xv., p. 197 (with clinical illustrations and survey of 
literature). 



134 DISORDERS OF THE GLANDS. 

pression, whether general or local, may be a congenital or acquired pecu- 
liarity of the individual, or may be a symptom of several disorders, 
but as an idiopathic cutaneous affection it very rarely occurs. This con- 
dition is common to many dermatoses, as, for example, ichthyosis, 
psoriasis, and some forms of eczema ; but in these the symptomatic 
character of the anomaly is illustrated by the fact that when the skin 
is relieved of these cutaneous troubles the function of sweat-secretion 
is restored. Similarly in neuralgias and certain forms of paralysis a 
circumscribed and temporary anidrosis may be the local expression of 
the nervous disturbance, precisely as in the case of the symmetrical 
hyperidroses. Lastly, there are individuals exhibiting the idiosyncrasy 
of either sweating not at all or quite imperceptibly in elevated tempera- 
tures, phenomena which should be ascribed rather to peculiarities in 
the equilibrium of the heat-exchanging factors than to congenital 
deficiency of the sweat-glands. 

Strauss and Bloch regard the occurrence of hypohidrosis and ani- 
drosis as differential diagnostic symptoms of diffuse myelitis, polio- 
myelitis, and cerebral paralysis. 

Treatment. — The measures capable of stimulating the sweat-secre- 
tion are : ingestion of water in quantity by the mouth, the external ap- 
plication of heat in a dry or moist atmosphere, and the use of jaborandi 
or pilocarpine by the mouth or by hypodermatic injection. In the 
anidrosis accompanying cutaneous disease the indication is always pri- 
marily for the relief of the latter. 

BROMIDROSIS.* 

(Gr. (3po)fiog } a stench; v6up } water.) 

(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat. 
Ger.j Stinkender Schweiss ; Fr., Bromidrose.) 

Symptoms. — In bromidrosis the perspiration is effused in such a 
state that immediately it can be perceived to possess an unusual odor, 
or, as Hebra taught was the case with the majority of patients, to be 
rapidly changed to that condition. It is often associated with hyperi- 
drosis, but may occur independently of the latter, and like the latter 
also be either general or localized. The odor may be either agreeable 
or disagreeable, having been in various cases compared to that of 
certain flowers and fruits as well as to that of several stench-emitting 
animals. In this respect the sweat presents a striking analogy to the 
urine, with which it sustains a close and well-recognized physiological 
relation. 

General bromidrosis may be physiological, as in the case of indi- 
viduals of the African race, or in those with dark skins who are pro- 
fusely sweating during labor or in high temperatures. General patho- 
logical bromidrosis is rare. The odors emanating from the person in 
ulcerating syphilodermata, small-pox, malignant pemphigus, mycosis 
fungoi'des, and other disorders may, in certain cases, be associated with 
the sweat-secretion, but in other cases they doubtless are connected 
1 For bibliography, see Torok, Mracek's Handbuch, Bd. i., pp. 413-415. 



BROMIDROSIS. 135 

with the decomposition of pathological products of the inflammatory 
process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess and its immediate evaporation pre- 
vented, as in the axillae, the groins, the feet, the anogenital and the in- 
termammary and inframammary regions. In a qualitative sense every 
degree of odoronsness is noted, from that which is merely slightly 
agreeable or offensive to the most intolerable stench. When com- 
plicated by a seborrhcea in situations where the parts are not only 
warm, moist, and covered by clothing, but also subjected to friction 
and remaining uncleansed, the most intolerable and nauseous fetor is 
perceived. As in hyperidrosis, there may be coincident or resulting 
redness, swelling, and even vesiculation or superficial inflammation of 
the region where the symptoms chiefly are declared. 

Sweat may be effused in a normal condition upon and within the 
articles of clothing worn, and subsequently generate a stench by chem- 
ical changes both in the clothing and the fluid by which that clothing 
is saturated. This fact should never be forgotten in the practical 
management of any case. 

Etiology and Pathology. — Thin has recognized micro-organisms 
{Bacterium foetidum) in sweat obtained from the feet. Parkes con- 
cludes that the only cause of the disease is the covering of the foot, 
as soldiers with uncovered feet do not suffer from this affection. It 
is occasionally due to emotional causes, to chronic alcoholism, or to the 
gouty state. Internal diseases, neurasthenia, and dietetic errors (meat- 
eating in excess, alcoholism, etc.) may be responsible for the affection 
at almost every age, and in individuals of either sex. In a mild form 
it is common in vigorous brunette women soon after the puberal epoch 
and during menstruation. 

Treatment. — The treatment of bromidrosis is in general that of 
hyperidrosis, already described. Internally sodium salicylate has been 
employed with success in 5-grain (0.33) doses. The regulation of the 
diet, and especially the disuse of alcohol and tobacco, are essential to 
the management of some cases. 

Formalin solutions in the strength of from 1 to 10 per cent, in 
alcohol are of the greatest value. They should be followed by the use 
of boric acid in powder externally. Thin 1 successfully employed stock- 
ings and cork-soles thoroughly dried after being saturated for hours in 
ajar containing a solution of boric acid. The efhcacy of this measure 
he ascribes to the fact that the odor is the result of the development in 
the secretions of Bacterium foetidum. An ointment is also employed 
by him for similar purposes ; it is a solution of boric acid in glycerin 
incorporated with a fatty basis of white wax and almond-oil, making 
thus a " glycerated cream of boric acid." Armingaud has reported excel- 
lent results following the subcutaneous injection of 3 grains (0.20) of 
pilocarpine nitrate, eight of which operations were successful in lessen- 
ing the abnormal sweat-fetor. Clement Hawkins 2 finely triturates 15 
grains (1.) of red lead oxide, and to this adds gradually 1 ounce (32.) 

1 Practitioner, December, 1881, xxvii., p. 2101. 

2 Brit. Med. Jour., May 7, 1881. 



136 DISORDERS OF THE GLANDS. 

of Goulard's extract. This preparation is used as a lotion following a 
nightly foot-bath containing 1 ounce (32.) of alum. 

Fox 1 advises a 1 per cent, solution of chloral or of potassium per- 
manganate as a topical application. Chromic acid solutions in 5 to 10 
per cent, strength, and potassium permanganate solutions in the strength 
of 1 part to 1000, may be employed. 

CHROMIDROSIS. 2 

(Gr. xptipa, color; vdup, water.) 

(Ephideosis Tincta, Coloeed Sweating, Steaeehcea Nigeicans, 

PlTYEIASIS NlGEICANS.) 

By this term is indicated the condition in which effused sweat exhibits 
an abnormal color — yellowish, reddish, greenish, or blackish. Cyani- 
drosis is the term that has been employed to indicate blue sweating. 
The sweat may be effused upon the surface as a colored fluid, or be com- 
mingled with substances which produce the abnormal color upon the 
surface of the skin (bacteria, dyes, chemical agents in themselves with- 
out color). 

In cases of chromidrosis there has usually been a copious secretion 
of sweat. Authors variously have attributed the color of the sweat to 
the presence of compounds of phosphorus, iron, cyanogen, indican, 
Prussian blue, hsematin, chromogen, and even to parasitic vegetations 
upon the skin-surface. Women, much more often than men, exhibit 
the free deposit of pigment upon the skin, and in view of the admitted 
rarity of chromidrosis the suspicion arises that in some of the cases 
reported there was free pigmentation of the surface, by which the fluid 
exuded at first colorless was stained later. Duhring reports a case of 
red sweating in a vigorous male patient. Usually, however, the phe- 
nomenon occurs in persons who are debilitated and betray some evi- 
dence of impairment of other organs than the skin, thus furnishing an 
indication for treatment. 

Babesiu, 3 of Pesth, reports some interesting cases of this disorder 
in which the symptoms were due to the presence of bacteria, a fact 
confirmed by us in several instances. In ten patients, five of them 
women, there was considerable pruritus with pale-red to blood-red 
sweat ; in one of the patients the skin and hairs were reddened. The 
axillae were the seat of this colored perspiration. In all the cases 
microscopical examination revealed similar changes. The hairs of 
the axillae were thin, pale red, brittle, and surrounded with a col- 
loid-looking, rusty, or bright-red sheath, in places of considerable 
thickness and having a rough surface. This sheath consisted of red 
masses presenting a radiating striation, more or less confluent, appar- 
ently proceeding from fibres of the cortex of the hair or from some 
broken part of its surface. The radiating striation was found to be 
due to the aggregation of round or ovoid bacteria (scarcely a micro- 

1 Brit Med. Jour,, May 7, 1881. 

2 For bibliography, see Barrie, Annales, 1889, s. ii., x., p. 937 ; and Torok, Mracek's 
Handbuch, Bd. i., pp. 404-413. 

3 Lancet, 1862. 



CHROMIDROSIS. . 137 

millimetre in diameter), which were united in zooglcea masses by a 
reddish intermediate substance. Nodular swellings on the hair were 
produced by the infiltration of the organism between the separated 
fibrils. The roots of the hair were free from bacteria. The red tint 
of the sweat was found to depend upon numerous roundish masses of 
zoogloeao 

T. C. Fox * reports also two cases of Cyanhidrosis in which a deep 
bluish-black pigment was exuded upon the skin of the circumorbital 
region. The amorphous granules were found insoluble in almost all 
hot or cold reagents, but they displayed a deep-blue color when moist- 
ened with glycerin, and a purplish hue when dissolved in hot sulphuric 
acid. 

Mitchell 2 describes an unusual case under the title of " Seborrhcea 
Nigricans," in which there was a dark greasy-looking discoloration 
of the eyelids and adjacent skin. Putnam 3 reports a case of inky- 
black chromidrosis of the eyelids and upper parts of the cheeks in a neu- 
rotic young woman, which was accompanied by amenorrhea and fre- 
quent attacks of hysterical paralysis. 

Etiology and Pathology.— The subjects of the disorder are chiefly 
women of neurasthenic type ; but we have recognized the symptoms in 
vigorous young men. The exuded coloring-matters may or may not 
be soluble in ether. 

The hypothesis, that certain cases described as chromidrosis are 
really instances of mechanical washing of pigment to the surface in the 
profuse sweating of the debilitated, is strengthened by the phenomena 
of simultaneous hair-coloration. Thus, Prentiss 4 reports the case of a 
young woman, affected with acute cystitis and passing purulent urine, 
whose hair, under the influence of profuse sweating induced by the 
action of pilocarpine, changed speedily from a light blonde to a nearly 
jet-black hue. At the meeting in 1881 of the American Dermatolog- 
ical Association we exhibited hairs of a middle-aged man that had 
changed in a night from a grayish-white to a greenish and yellowish- 
brown hue. White, of Boston, has observed several similar cases of 
hair-coloration as the result of profuse sweats. In the year 1884 this 
observer reported to the Association the case of a workman in a sugar- 
refinery whose sweat from the left side of the body was of a bright- 
yellow color for several months. Though sought for, no bacteria were 
discovered. 

In a case observed by Bergmann a mycelium was recognized which 
was subsequently cultivated. Eberth has recognized bacteria in both 
normal and yellow sweat. 

Le Roy de Mericourt, first to name this disorder/ also 6 described a 
case of rosy sweating in an infant. 

Fereol believes that in these cases there is actually an absence of 
sweat, and prefers to call the disorder " chromocrinia." 

1 Brit. Med. Jour., 1881, i., p. 921. 

2 Phila. Med. Jour., 1898, i., p. 117. 

3 K Y. Med. Jour., 1903, lxxvii., p. 26. 

4 Phila. Med. Times, 1881, xii., p. 385. 

5 Arch. gen. de Med., November, 1857. 

8 Bull. Acad, de Med., 1884, 2 e s., xiii., p. 425. 



138 DISORDERS OF THE GLANDS. 

Hall 1 reports several cases in which a supposed cyanidrosis was 
found to be due to cheap black stockings, the dye of which when 
brought in contact with acid sweat produced a peacock-blue discolora- 
tion of the toes. 

Heidi ngsfeld 2 reports a yellowish-brown pigmentation limited to 
the right forearm and appearing about one year after the man had 
recovered from an attack of jaundice. Histological examination showed 
the sweat-glands to be normal ; an absence of the sebaceous glands ; an 
hyperkeratosis around the mouths of the hair-follicles ; and a pigment 
grouped in cell-like masses about the hair-follicles in the stratum cor- 
neum, lower layers of the rete, and adjacent cutis. Chemical and 
spectroscopic tests showed that the pigment was not derived from oxy- 
hemoglobin. 

In all cases, before accepting statements of patients as to the exist- 
ence of symptoms of this character, it is needful to eliminate the possi- 
bilities of deceit and accident. Coloring-matters received upon the 
hands may be either wilfully or ignorantly transferred to the surface 
of the body. 

Greenish sweating, due to the presence of copper in the system, 
has been reported in a few instances. We have observed one case of 
this disorder in which the effect was produced by the copper plate of an 
electrode in contact with an abraded surface of the skin. 

Phosphorescent Sweating is reported to have occurred after the 
eating of phosphorescent fish and the ingestion of phosphorus for 
medicinal purposes. 

The Treatment of these several conditions is that of the general 
state of the patients exhibiting these symptoms. 

URIDROSIS. 3 

(Gr. ovpov, urine ; v Sup, water. ) 

(Ger.j Harnschweiss ; Fr., Uridrose.) 

Uridrosis is that condition in which some of the constituents of the 
urine, chiefly urea, are excreted in excess with the sweat. 

While a small amount of urea is to be recognized in normal sweat, 
this ingredient under peculiar conditions may be increased, and, together 
with urinary salts, be deposited upon the skin-surface after evaporation 
of the exuded fluid. Such symptoms have usually occurred either as the 
result of grave constitutional affections (such as cholera), or of organic 
renal diseases accompanied by anaemia, or of the ingestion of jaborandi. 
In a few cases the symptoms have been presented in individuals who 
were apparently in good health. The salts of the urine appeared upon 
the skins of these patients in the form of minute lamellae, or of a fine 
powder of whitish color and crystalline aspect. In some cases reported 
the symptoms have been noted to precede by a few days a fatal issue. 

The constantly adjusted equilibrium between the sweat-secretion and 

1 Brit. Jour. Derm., 1902, xiv., p. 418. 

2 Jour. Am. Med. Assoc., 1902, xxxix., p. 1519 (with bibliography). 

3 For bibliography, see Torok, Mracek's Handbuch, Bd. i., pp. 415, 416. 



URIDROSIS. 139 

the urinary excretion would explain, for cases 01 a mild type, tem- 
porary augmentation in the urea found in the sweat of unusually free 
diaphoresis. Geber supposes that decomposition-products, such as 
ammonium carbonate, possibly in association with volatile fatty acids, 
may in part account for these conditions. 

In the effort to eliminate certain substances accidentally or pur- 
posely introduced into the system the sweat may possibly become 
charged with iodine, turpentine, tar, arsenic, and other substances. 
Several of the eruptions described in the chapter on Dermatitis Medica- 
mentosa are due to a similar eliminative effort, especially those accom- 
panied by excessive sweating and the production of vesiculation. In 
the same manner it may be inferred that the sweat is at times charged 
with excrementitious and other products of the body ; as, for example, 
the elements of the bile. In patients affected with yellow fever the 
skin and even the sweat which exudes from it often exhibit the char- 
acteristic hue of that disease. The so-called Galactidrosis, from 
supposed metastasis of milk, does not occur ; cases thus described have 
been instances of pathological sweat in the puerperal state. 

Phosphoridrosis, 1 in which a phosphorescent quality has been 
imparted to the sweat secretion, is reported in rare cases to have re- 
sulted from ingestion of phosphorescent fish, and in such wasting dis- 
eases as pulmonary tuberculosis, tabes, and scurvy. 

ILematidrosis 2 (Hemidrosis, Sudor Saxgttixeosa, Bleedixg 
Stigmata, Neurotic Excoriations, Bloody Sweat), reported as 
observed by several authors (Foot, Ebers, Parrot), is the name applied to 
conditions in which blood has been seen to exude from an unbroken skin. 
The phenomena described under this title belong properly to the ensem- 
ble of symptoms called " haemophilia," and may in some cases be due to 
direct transudation of red and white blood-corpuscles and fibrin into the 
interepithelial spaces traversed by the sweat-pores. Geber points to the 
neuralgic, hypersesthetic, pruritic, or emotional symptoms that are usual 
precursors to the flow of pale or bright-red blood. The fact that 
patients thus affected are mostly women, hysterical, dysmeuorrhoeic, 
or near the puberal epoch, also throws light upon these cases ; in many 
of them petechia?, or signs of hemorrhage into other tissues of the 
body, are observed. 

The bleeding may occur from a single point, or from several in 
succession, or simultaneously from multiple stigmata. There may be 
a precedent elevation of the surface forming vesicles, blebs, macules, or 
papules ; or the skin at the site of the hemorrhage may be unaltered. 
Gangrene has resulted in a few instances. Often pain or other sensa- 
tions announce the occurrence of the bleeding. 

Treatment. — Special caution is to be taken lest patients com- 
plaining of these symptoms solicit the hemorrhage by self-injury. In a 
few cases the persistence of the sanguineous flow has induced a dangerous 
anaemia. The treatment is that indicated by the conditions present. 

1 See Merks' case, Wien. klin. Wchnsckrft, 1903, xvi., p. 1091. 

2 For bibliography, see Torok, Mracek's Handbuch, Bd. i., pp. 416-418. 



140 DISORDERS OF THE GLANDS. 

2. DISORDERS OF THE SEBACEOUS GLANDS. 

SEBORRHEA. 

(Lat. sebum, tallow; Gr. pew, to flow.) 

(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Seba- 
ceous Flux, Stearrhoea. Ger., Schmeerfluss ; Fr., Sebor- 

RHEE.) 

The clinical phenomena described under the title of seborrhea are 
not due solely to a catarrh of the sebaceous glands, but result from 
several different pathological processes in which the coil-glands and 
epidermal layers are more or less involved. In the absence of suffi- 
cient knowledge of the pathology of these conditions they are in these 
pages considered chiefly from a clinical point of view. The inflamma- 
tory processes in which the fat-producing glands seem to play an 
important part are described under the title eczema seborrhoicum. 

Symptoms. — Seborrhoea occurs in two forms. According to the 
condition of the excreted product, they are described as seborrhcea 
sicca and seborrhoea oleosa. These two forms are recognized clinically 
as of separate occurrence, and also as existing occasionally at the same 
time in one person. Either form of the disease may be limited to 
certain sites of preference, or be generalized so as to extend over all 
portions of the body provided with sebaceous glands. The commonest 
seats of the disease are: the scalp, the face, the genital region, the 
dorsum of the body between the scapulae, and the anterior surface of 
the chest. It appears at all periods of life and in both sexes. As 
the sebaceous glands are mainly appendages of the hair- follicles, the 
lesions of the disease differ somewhat according as they exist in the 
regions covered with long or with lanugo-hairs. For the same reason 
a difference marks the career of the disease. At times it is a trivial 
and short-lived affection ; at other times it is persistent and intractable, 
lasting for years and possibly for a lifetime. The individuals thus 
affected exhibit a difference also with respect to the condition of gen- 
eral health. Some are anaemic, chlorotic, or asthenic; some are of 
sanguine temperament, fleshy, red-faced, and thick-skinned; others 
again are absolutely healthy, so far as can be discovered, except for the 
local sebaceous disorder. The latter fact is of some significance. One 
may see extreme types of seborrhoea in vigorous men who have worn 
merely for one month a skull-cap to which was fastened an apparatus 
for relief of fracture of the lower jaw. The skin affected with a sebor- 
rhoea is usually anaemic, and is either dry or humid. The subjective 
sensations are either slight and limited to a moderate degree of itching; 
of which the patient does not complain until he is questioned upon the 
subject, or these sensations are altogether wanting. At other times the 
glands or periglandular tissues are affected with a mild form of inflam- 
mation, and then the involved surface may be reddened and become 
the seat of a considerable pruritus. 

Seborrhoea Oleosa. — This form of seborrhoea, variously known as 
hyperidrosis oleosa (Brocq), seborrhoea simplex (Unna), stearrhoea sim- 
plex (Wilson), acne sebacee fluente, etc., is in its pronounced features 



SEBORRHCEA. 141 

rarer than seborrhoea sicca, but to a less degree it is a condition suffi- 
ciently common in many forms of the disease. The sebaceous secretion 
is exuded as an oily fluid upon the surface both of the hairy and so- 
called " non-hairy" parts of the skin. In the former situation, both in 
adults and infants, the free oily substance is seen to cover as a coating 
both skin and hairs, and, especially in bald adults, to produce a glisten- 
ing and shining appearance of the scalp. In women with long hair 
the locks are often matted together in a glue-like paste. The secretion 
often concretes into masses, forming the crusts of seborrhoea sicca. 
The same greasy layer can be seen over the non-hairy portions of the 
skin, especially about the nose, forehead, and cheeks. "When the face 
is involved, there is usually a characteristic muddy and soiled aspect 
of the skin. Free drops of oil can occasionally be wiped from such 
surfaces with a handkerchief. The ducts of the sebaceous follicles here 
are either patulous or plugged with comedones ; the skin-surface may 
be reddened or be pallid, but it is usually cold to the touch. Rarely 
it is the seat of a mild grade of inflammation. The oily substance 
serves to entrap particles of dust, soot, etc., floating in the air; 
thus a peculiarly dirty or even blackish hue of the face is often pro- 
duced. This form of seborrhoea, though most common on the face 
and scalp, may occur on the chest, the back, the pubes, the genitals, 
and rarely on the other parts of the body. In the negro, in whom 
the sebaceous glands are usually well developed and active, the oily 
forms of seborrhoea are common, and the flux at times is practically 
physiological. Even in the absence of their frequent anointing with 
palm-oil, one can see in Africa naked blacks whose skins shine from 
exuded grease. 

Subjective symptoms in seborrhoea oleosa are usually slight, though 
a moderate amount of itching is commonly present. On the scalp the 
disease often produces an alopecia which does not, as a rule, respond 
readily to treatment. 

Seborrhoea Sicca. — Seborrhoea sicca, as the term is generally accepted, 
varies greatly in its manifestations, but in general its features may be 
divided into the scaling and the crusting form of the disease. The scal- 
ing form, variously known as seborrhoea furfuracea or pityriasiformis, 
pityriasis simplex, eczema seborrhoi'cum, eczema squamosum, etc., is most 
common on the scalp, in which region it is popularly known as " dan- 
druff." Seborrhoea capitis in its commonest form is recognized in the 
adult by the formation on the scalp of fine, branny, slightly greasy, 
white or grayish scales, which may be so abundantly shed as to fall 
freely and cover the shoulders of the patient whenever the hair is 
brushed or otherwise disturbed. At other times these fatty scales are 
more or less adherent to the scalp-surface, or are piled up in laminae 
one upon another. These scales may mat the hairs to the scalp 
or be disseminated through the mass of the hair, some of the hairs 
penetrating a flattened greasy scale, as a twig might be passed through 
the centre of a leaf. In consequence of their deprivation of unguent 
the hairs to which the affected glands are accessory become dry and 
lustreless, and fall from their follicles. If the process be not arrested, 
atrophy of the hair-follicles ensues, the resulting alopecia becoming 
permanent. 



142 DISOBDERS OF THE GLANDS. 

Fortunately, the seborrhoea is usually symmetrical, and, in like 
manner, the baldness which it occasions. The resulting disfigurement 
is of the character of symmetrical senile alopecia, which is chiefly 
annoying because of the premature loss of hair. When this loss is 
asymmetrical, which is decidedly exceptional, the disfigurement is 
greater. 

The affection may be circumscribed, and in conspicuously exhibited 
patches covered by thin, mealy, grayish or whitish scales ; or thick 
yellowish masses may paste the hairs firmly to the surface of the scalp. 
The disease may extend uniformly over the entire surface of the scalp, 
or, as is frequently noticed, may fringe the brow at the line of the 
hairs and then extend chiefly over the vertex, being conspicuous at the 
line where the hairs are parted from vertex to brow. 

Beneath the scales or crusts of dried sebum the scalp is usually 
lustreless and of a slate-gray color. As the disease does certainly at 
times exhibit intermediate between functional and inflammatory forms, 
the adjacent tissues may present a hypersemic or even an exudative 
feature, with true epithelial desquamation and considerable itching — 
alopecia pityroi'des, pityriasis simplex. One group of cases, assign- 
able to this class, deserves mention. In these cases there is a tol- 
erably well-diffused seborrhoea sicca of the scalp, and irregularly 
distributed over the surface are filbert-sized, generally circular, dark- 
reddish patches, covered with a moist secretion or a friable, gran- 
ular, reddish-yellow crust. These patches are scalp "excoriations" 
produced by the finger-nails. They are most common in " nervous" 
patients, who cannot resist forcibly digging the scalp on the slightest 
provocation. 

The eyebrows, the region covered by the beard, and the pubic hairs 
may be affected, although less frequently, in the manner described above. 
In the latter region the itching is often more severe than when the 
disorder is limited to the scalp. The disease not infrequently extends 
from the scalp to the adjacent portions of the face, neck, and ears. In 
these situations the skin is usually slightly reddened, while the scales 
are thin, adherent, and not very abundant. These features may appear 
on the portions of the face more distant from the scalp, and on other 
parts of the body, in the form of dry, roughened patches which scale 
more or less, but which are only slightly, if at all, reddened. On such 
surfaces the condition may shade insensibly into those described under 
eczema seborrhoicum. 

The crusting forms of seborrhoea may occur on any of the hairy or 
non-hairy parts of the body, but are most common on the scalp and 
face. The so-called " waxy " form is represented by the physiological 
vernix caseosa of the newborn infant, and by the more or less adherent 
dirty-yellowish cap often long surviving upon the vertex of young 
infants. Occurring later in infancy, the disease is known as " milk- 
crust," or as crusta lactea. This may merely be persistence of the dried 
vernix caseosa about the vertex in the newborn, or it may occur in 
scalps which have been perfectly cleansed after birth. The crust differs 
somewhat in color with the tint of the child's complexion, and may vary 
from a light yellow to a dark brown ; it may be thick, greasy, and mat 



SEBORRHEA. 143 

the hairs ; or be thin, dry, and friable. This crust is a frequent com- 
plication of the eczematous disorders of the scalp, and, as a consequence, 
every variety of hyperemia and inflammation may affect the tissue 
beneath the crust. In infants and children, however, the resulting 
alopecia is never permanent, as the rapidly growing follicles hasten 
to reproduce the hair. The disease is neither contagious nor followed 
by cicatrices, points upon which mothers are usually solicitous. The 
region of the brow, the surface covered by the beard of the male, and 
the pubic hairs may be involved in this type of the disease, though less 
frequently than in the furfuraceous form. 

The so-called " flower-leaf" type of seborrhoea (petaloides) is seen 
chiefly upon the anterior and posterior surface of the upper part of the 
trunk, especially over the sternum and between the shoulders. Here 
occur sharply defined patches slightly elevated at the margin, reddened 
in various shades, the color diminishing from periphery to centre. The 
resemblance to a flower-leaf is in many cases striking ; often a clover- 
leaf is suggested by three foliate patches united more or less distinctly 
at a common point. These features are more often encountered in men 
with a hairy chest, the faintly reddish patches gleaming between the thick 
and strong pilary filaments. In all these cases careful examination will 
reveal the seborrhoeic state of the patient either by discovery of a 
seborrhoea of the scalp, or of acne of the face, etc. 

On the face this form of seborrhoea is characterized chiefly by the 
accumulation of thick, dirty-yellowish, and even yellowish-black accu- 
mulations of sebaceous matter, often adherent to the surface and disfig- 
uring the features by the mask produced. This condition is conspic- 
uous about the nose, where the disease is at times symmetrically dis- 
posed. The crusts once removed, the skin beneath is generally found 
to be pallid or slightly reddened, with the orifices of the sebaceous 
ducts patulous ; while the under surface of the separated crust is seen 
to project downward in corresponding delicate prolongations compara- 
ble to stalactites. The crusts rapidly reform when the disease is not 
arrested. They are found in the furrows on either side of the nostrils, 
on the brows, the cheeks, and the pavilion of the pinna of the ear. 
They are most common at the puberal epoch in both sexes, when the 
sebaceous glands of the skin undoubtedly sympathize w T ith the changes 
occurring at the beginning of the sexual life. 

Seborrhoea may affect the eyelids, which are then reddened, slightly 
swollen, and in various degrees covered with minute crusts (less fre- 
quently with scales). The eyelashes often fall, and in cases of long 
standing their loss may be permanent owing to atrophy of the 
follicles. 

Seborrhoea of the umbilicus assumes special features, since the fatty 
matters in this region are remarkable for their tendency to speedy 
decomposition, with the production of an exceedingly fetid odor, which 
may prove to be the source of a mild grade of inflammation. In the 
latter event a reddish halo surrounds the umbilical depression, which 
may furnish a thin sero-purulent discharge. 

Seborrhoea of the genitals in men is usually located in the sulcus 
behind the corona glandis, though in individuals with a tight or a redun- 



144 DISORDERS OF THE GLANDS. 

dant prepuce it may be more extended. In women the accumulation 
occurs about the clitoris and vestibulum, though the external labia may 
be covered with the secretion in various degrees of fluidity. The 
smegma preputii supplied by the glands of Tyson may thus be the 
source of trouble either by its retention or its secretion in abnormal 
quantity or quality. In either event the tendency, as in umbilical 
seborrhoea, is to decomposition, fetid odor, and subsequent irritation, 
which may provoke inflammation of severe grade. The retention of 
this smegma beneath a tight or a redundant prepuce in men may be the 
cause of many reflex symptoms, such as incoordinated movements of 
the lower extremities, nocturnal enuresis and pollutions, hernia, and 
irritability of the testis. In some cases the secretion forms a ring (as 
hard as the rind of cheese) encircling the glans. The young of both 
sexes as well as adults are liable thus to be affected, and in young 
female children these symptoms may have a medico-legal interest in 
connection with suspicion of criminal assault. 

Seborrhoea generalis, affecting the entire surface of the body, is an 
exceedingly rare disorder. In the infant (Seborrhgea Squamosa 
Neonatorum, Ichthyosis Sebacea) the skin is universally spread 
with a greasy layer, which is rapidly renewed after removal, and 
beneath which the skin appears to be varnished in reddish-brown 
shades. The consequent stiffening of the integument produces painful 
fissures, inability to take the nipple, and consequent marasmus. 

In adults the disease may occur in marasmic subjects and in old 
people in the form of a persistent fine scaling on the trunk and extensor 
surfaces of the limbs, and is known as "Pityriasis Tabescentium." A 
yet rarer form is described by Kaposi under the name of "Cutis Tes~ 
tacea," in which large portions of the skin, especially the extensor sur- 
faces of the limbs, are covered with greenish-brown or blackish crusts 
which are more or less broken up into plates. 

Etiology. — The disorder, except that form which appears in in- 
fancy, is most frequent at the age of puberty or in young adults — that 
is, at the time of greatest activity of the glands. It occurs about 
equally in both sexes, though it is more frequent in women after the 
menopause. Seborrhoea oleosa is found more frequently in persons of 
dark complexion, while seborrhoea sicca is more common in blondes. 
A family tendency to furfuraceous seborrhoea of the scalp, with the 
resulting alopecia, may often be noted. 

Among the predisposing causes may be counted all systemic dis- 
turbances which lower the vitality and general nutrition. Seborrhoea 
may thus follow the exanthemata, and frequently appears during the 
course of chronic exhausting diseases, such as syphilis or tuberculosis. 
Constipation, indigestion, sedentary habits, and the excessive use of 
alcohol and tobacco may be classed among the predisposing causes. 
The disease occurs, however, in individuals who are apparently in 
excellent health. Among the local predisposing causes are the wearing 
of stiff, heavy, and ill-ventilated hats, and the failure properly to care 
for the scalp. Women with long hair are generally disposed to take 
special care of the scalp. Men with short hair attend chiefly to its 
disposition upon the head, and often neglect the care of the scalp. 



SEBORRHCEA. 145 

Such neglect is followed frequently by seborrhcea sicca when no other 
cause for the disorder can be found. 

Pathology. — Although the pathology of diseases of the sebaceous 
glands, including seborrhcea, comedo, acne and acne rosacea, has been 
studied by many competent observers, there yet exists a diversity of 
opinion regarding the nature and pathogenesis of these affections. The 
conservative view, based on the teachings of Hebra, is that seborrhcea is 
a functional disease of the sebaceous glands, manifested in hypersecretion 
of pathologically altered sebum, and often accompanied by some hyper- 
trophy of the glands. In the oily form, the sebum is secreted in 
excessive quantities and may be more fluid than normal. As a rule at 
puberty, and in some individuals throughout their lives, the quantity 
of oily sebum excreted is larger than usual, and it is not always possible 
to draw sharp dividing-lines between the physiological and the patho- 
logical process. In the dry form of seborrhcea the secretion is dryer 
than usual and mixed with cells exfoliated from the ducts of the glands 
and hair-follicles, and with imperfectly metamorphosed cells from the 
glands themselves. Unna l believes that the skin is lubricated by oil 
from the coil-glands, and that in seborrhcea oleosa (which he terms 
hijperidrosis oleosa) the secretion is practically all furnished by them, 
the sebaceous glands being involved secondarily if at all. Beatty 2 
states that the coil-glands do not furnish the oily secretion in this con- 
dition. Sabouraud 3 states that seborrhcea oleosa (also comedo, acne, 
and alopecia areata) is due to an inflammation of the sebaceous glands, 
caused by a definite micro-bacillus which is found w T ithin a cocoon- 
shaped mass of epithelium at the neck of the follicle. 

It is generally believed that the coil-glands secrete fat, but how 
much they supply and what part they play in seborrhcea are unsettled 
questions. The fact that seborrhcea is most frequent and most pro- 
nounced in regions where the sebaceous glands are largest and most 
numerous is fairly good evidence that these glands more than the sweat- 
glands are active in the production of the disease. 

In seborrhcea sicca the scales are produced from the horny layer of 
the scalp and not from the gland. This fact was demonstrated by 
Hardaway in 1878, and since that date by Unna, Sabouraud, and 
others. Sabouraud states that simple pityriasis of the scalp is due to a 
flask-shaped bacillus and to a coccus producing gray cultures. The 
cases with greasy scales he thinks are the result of superficial inflam- 
mation, added to pre-existing seborrhcea oleosa. Unna finds in sebor- 
rhcea sicca several micro-organisms (see Eczema Seborrhoicum) which 
he believes to be the cause of the disease. 

While there is much, both in clinical experience and in laboratory 
findings, to commend the theory that seborrhcea is of parasitic origin, 
no one micro-organism has yet been demonstrated to have a definite 
etiological relation to the disease. Moreover, the sebum retained in 
the follicles furnishes an excellent culture-medium for an unusual 
development cf micro-organisms which may be found on the scalp in 

1 Brit. Jour. Derm., 1894, vi., p. 257 ; and Histopatkology, p. 222. 

2 Brit. Med. Jour., 1901, ii., p. 858 ; and Les Maladies du Cuir chevelu, Paris, 1902, 

3 Brit. Jour. Derm., 1894, vi., p. 161. 

10 



146 DISORDERS OF THE GLANDS. 

normal conditions. Schamberg 1 has demonstrated Sabouraud's micro- 
bacillus in the follicles of individuals having no signs of seborrhoea or 
of other diseases of the sebaceous glands. 

Unna and Eiliott state that the microscope shows inflammation to 
be present in all but the simple oily form of seborrhoea (see Eczema 
Seborrhoicum). It is impossible to draw sharp dividing-lines between 
tbe types here described which clinically show little or no evidence of 
inflammation, and the distinctly inflammatory forms described as eczema 
seborrhoicum. 

Diagnosis. — Seborrhoea is to be distinguished from : 

Eczema. — The objective points of difference between eczema and 
seborrhoea depend upon the inflammatory character of eczema, upon 
the reddened, infiltrated, or discharging skin, and upon the consider- 
able itching which it occasions. In squamous eczema the scales are 
rarely so abundant as to be shed freely from the surface, and are not 
greasy. It should be remembered, however, that the two diseases often 
coexist. Inflammation of those parts of the skin well supplied with 
sebaceous glands usually assumes one of the types described as eczema 
seborrhoicum. Eczema of the scalp in infants is frequently accom- 
panied by a seborrhoea, a fact which clearly shows that the technical 
distinctions between many diseases, useful though they be for analytical 
study, are not always capable of clinical demonstration. 

Ichthyosis.— This is a congenital disease, usually involving the en- 
tire surface of the body, while seborrhoea is generally acquired and is 
rarely universal. The distinction between ichthyosis and the rare gen- 
eralized forms of seborrhoea described above might involve a difficulty ; 
but in the latter the greasy character of the crusts, their color, and the 
marasmic condition of the subject would sufficiently distinguish the two 
disorders. 

Impetigo. — The only possibility of error in diagnosis would occur 
during the crusting stage of impetigo upon the scalp. But impetigo is 
an acute disease, with comparatively small, circumscribed, and isolated 
lesions, with crusts differing in character from the sebaceous matters 
formed in seborrhoea, and beneath such crusts the integument is red- 
dened and evidently the seat of an exudation. 

Lupus Erythematosus. — Lupus erythematosus occurring chiefly on 
the face, is rarer on the scalp ; it is accompanied by characteristic 
changes in the structure of the skin, and is often followed by a scar. 
Its lesions are darker red than the congestive patches beneath certain 
seborrhoeas of the non-hairy parts. The scales of lupus are tenacious 
and dry, and require scraping for their removal ; those of seborrhoea 
are greasy and more readily detached. The contour of the seborrhoeic 
patch is ill-defined compared with that of lupus, which is very distinct, 
exception being made of the mask-like crusts seen in certain of the 
facial seborrhoeas, in which the greasy character of the layer is very 
evident. Hebra, in 1845, described a " seborrhoea congestiva," which 
it would indeed be difficult to distinguish from lupus erythematosus, as 
the former is really an early stage of the latter. Typical cases of the 

p. 99. 



SEBORRHCEA. 147 

two diseases are widely different and readily distinguished ; the atypical 
forms might lead to confusion. 

Psoriasis. — Psoriasis of the scalp may resemble seborrhcea sicca, but 
the latter is rarely developed in such a universal exanthem as is fre- 
quent in the former. There will come under observation few doubtful 
cases in which a psoriatic patch on an elbow, a knee, a leg, or over the 
sacrum will not point to the nature of the disease. The scales of 
psoriasis are lustrous, larger, and not greasy unless fatty applications 
have been made to soften them ; and, moreover, they cover a reddened 
and exuding patch of integument. Psoriasis of the scalp and face 
prefers the areas of the forehead adjacent to the hairs of the scalp 
and rarely departs boldly to the nose and the furrows beside the nos- 
trils — favorite sites of seborrhcea. In seborrhcea of the scalp the hairs 
are loosened and fall, a condition not present in psoriasis. 

Syphilis. — Some of the pustular syphilodermata located upon the 
scalp and face, if observed only in the stage of crusting, might be 
confounded with seborrhcea. Here the history of the case, the discov- 
ery of other signs of syphilis (adenopathy, mucous patches, etc.), and 
the character of the secretion and the surface beneath the crust, 
together with the smaller size, more definite outline, and characteristic 
grouping of the lesions, should point to the identity of the disease. 
In syphilitic crusts about the angles of the nostrils there is often a 
peculiar reddish-brown tint of the skin at the edge of the patch, 
the so-called " copper" color, which is significant. Crusts of the 
hairy scalp in syphilis are very often accompanied by post-cervical 
adenopathy, and especially by indurated enlargement of the occipital 
glands. 

Tinea Circinata and Tinea Tonsurans. — In ringworm of the hairy 
parts, as also of the body, the microscopical discovery of the parasite 
will always point to the nature of the disease. Upon the scalp the 
affected patches are seldom so diffuse as in seborrhcea, are usually circu- 
lar, are often accompanied by fragility of the hairs, and in the latter 
case the discovery of stumps of hairs is significant. There are also a 
history of contagion and an absence of the greasy conditions of the 
scales characteristic of seborrhcea. 

Treatment. — The general and internal treatment of seborrhcea should 
be varied to meet the requirements of the individual case. The prep- 
arations most often indicated are : iron in anaemic young women, cathar- 
tics in sluggishness of the bowels, and cod-liver oil when there is impair- 
ment of nutrition. Duhring recommends calcium sulphide in doses of 
from y 1 ^- (0.0066) to ^ (0.0133) of a grain. Arsenic, employed in the 
manner suggested by Sir Erasmus Wilson, is praised by Hebra : 

R Vin. ferri, f^jss; 45 

Syrup, simpl., ) - - f _.. . R 

Liq. potass, arsenit., } ddIdIJ ' 5 

Aq. destill., f gij ; 60 M. 

Sig. A teaspoonful to be taken three times daily with the meal. 

In many cases the acid iron mixture of Startin, or some modifica- 
tion of it, admirably meets the indications present : 



Magnes. sulph., 


3y; 


60 


Ferri sulph at., 


Bss-9j ; 


0.66-1 


Acid, sulph. dilut., 


f3ij-f3iv; 


8-16 


Infus. quassise, 


adf^iv; 


120] 



148 DISORDERS OF THE GLANDS. 

R 

33 

M. 

Sig. A teaspoonful in water, to be taken through a tube after eating. 

The preparations of matzool, malt, and maltine, now largely em- 
ployed in the treatment of wasting diseases, will be found available in 
cases in which cod-liver oil cannot be well taken. Lastly, the bitter 
tonics may be needed. Throughout the treatment the physician should 
insure a careful observance of the laws of hygiene. Sunlight, nutri- 
tious food, and open-air exercise are not to be disregarded. Many 
young women of indolent habits are greatly benefited by sending them 
daily to riding-schools for an hour's equitation. 

In cases in which it can be tolerated, daily cool salt-and-water 
sponging of the entire body-surface, followed by brisk friction, may 
be employed with advantage. The salt is added to the water in the 
strength of \ pound to the gallon. There is no advantage to be gained 
by using the preparations of " sea-salt " sold in the shops. The bath 
is omitted during the menstrual period in women, and in the case of 
delicate patients. It is, without question, the most valuable of hygienic 
measures in the management of the disease. 

The first indication to be met by local treatment in seborrhoea is the 
removal of the crusts and the fatty matters accumulated upon the 
surface. It is always well to warn patients, especially if the disorder 
be upon the scalp in an aggravated form and occur in young women 
with apparently luxuriant tresses, that a considerable loss of hair 
will result. Many of the hair-filaments are so impoverished by the 
disease and so loosened in their follicles that a complete cleansing 
of the scalp-surface will bring the hairs away in quantities sufficient to 
threaten speedy baldness ; and it is not rarely the case that patients 
attribute this to the treatment rather than to the disease. The fatty 
accumulations are first to be soaked with some oily fluid to facilitate 
their removal ; for this purpose olive-oil, cod-liver oil, vaselin, cold- 
cream salve, almond-oil, glycerin, or lard is usually employed. The 
substance selected should be used in quantity sufficient to permeate 
all crusts. It may be poured over or be rubbed into the scalp several 
times in the twenty-four hours, and at night a flannel or other cap 
should be worn. In the case of children and infants gentleness is 
required in thus treating the scalp, especially in the subsequent wash- 
ings, lest the surface be irritated. In young women it is rarely neces- 
sary to cut the hair. As soon as the soaking with oil is complete the 
crusts are to be removed by washing with soap and water, though when 
the accumulations are bulky, masses may be gently removed with the 
fingers or a comb. When the scalp is tender ordinary toilet or Sarg's 
glycerin soap may be applied with warm water ; but it is usual, in the 
case of adults, to employ the spiritus saponis alkalinus of Hebra — 2 
parts of green soap digested in 1 of alcohol, filtered, and flavored 
with lavender or bergamot. The surface should be thoroughly sponged 
with the spirit, and then warm water added until lather is abundantly 
produced over the scalp, when an excess of water is finally used to 



SEBORRHCEA. 149 

cleanse the part of crusts, oil, and soap. The scalp and hairs are then 
thoroughly dried and anointed with some bland, fatty substance if the 
exposed surface be tender and irritable ; if not, with some stimulating 
pomade or lotion. 

In cases in which milder effects are required the scalp may be washed 
with water containing such alkaline substances as borax, ammonia, or 
potassium carbonate. The popular prejudice against these articles is 
based upon the abuse of strong alkaline lotions in the hands of inex- 
perienced persons. Such lotions may readily be tested by the tongue 
before use upon the scalp. They should in all cases be followed by 
an oily or greasy application medicated to meet the requirements of the 
case. 

The last-named precaution is an important one. However extensive 
the seborrhceic crusts, it is possible to remove them completely in every 
case by the measures described above, and with the first treatment 
patients are often delighted. Their disappointment is correspondingly 
great when they discover that the seborrhcea is not at an end, and 
that in the course of a few days the fatty plates are as freely as ever 
deposited on the scalp, disseminated through the hairs, and showered 
upon the shoulders. Some will even declare that the soapy applications 
aggravate the disorder by increasing the seborrhcea. It should, there- 
fore, never be forgotten that, having disposed of the extraneous matters 
accumulated upon the surface, there is still to be remedied a functional 
disorder of the sebaceous glands of the part. 

In every case, then, after the use of soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, 
or once a week, the scalp is to be thoroughly anointed. For this pur- 
pose olive-oil, cod-liver oil properly scented, almond-oil, vaselin, or 
glycerin and water may be used. Van Harlingen recommends, as a sub- 
stitute for other oils, the oleum sesami (oil of benne), since it does not 
dry and clog as do the former. An ounce (30.) of this oil rubbed up 
with 5 grains (0.33) of powdered benzoin, and digested for three hours 
over a water-bath, with the addition of 3 drops of absolute alcohol, 
and filtered, furnishes an excellent basis for oily mixtures to be used on 
the scalp. 

Morison l has devised an ingenious instrument for the application 
of oily lotions to the scalp. The fluid is contained in a small reser- 
voir, to which is connected a comb with perforated teeth ; through the 
latter the substance selected for medication of the scalp readily passes 
down to the surface between the hairs. A medicine-dropper, though 
less convenient, will answer the same purpose. 

In the place of oils after these ablutions pomades are often used 
with more advantage. For this purpose vaselin, lanolin, lard, and the 
zinc-oleate ointment furnish the best bases. To obtain the desired 
consistency, any one of these may be used alone or in combination 
with the others or with an oil. 

Crocker advocates prior to the application of oily preparations to 
the scalp the use of a lotion containing acetic acid, the object being to 
aid the penetration of the remedy. 

1 Maryland Med. Jour., 1885, xii., p. 311. 



150 DISORDERS OF THE GLANDS. 

Of the many remedies employed and recommended, resorcin, sul- 
phur, and the red oxide, bichloride, or amnion io-chloride of mercury are 
the most serviceable. Resorcin alone gives satisfactory results in the 
great majority of cases. This remedy may be used in a spirit lotion 
(from 25 to 75 per cent, of alcohol) in strength varying from 2 to 10 
per cent., or in the form of an ointment, 10 to 60 grains to the ounce 
(0.66-4. to 30.). Lotions are well adapted to cases in which there 
is little inflammation and in which decided stimulation is required. 
As they are cleanly and easy of application, they are more pleasing to 
most patients, and especially to women with long hair. Their efficacy 
is often enhanced by the addition of a small amount of oil. Mercuric 
chloride is admirably adapted for use in lotions. A good formula is 
as follows: 



R 



Sig. To be rubbed into the scalp. 



Resorcin., 


Sijss ; 


10 


Hydrarg. bichlorid., 


gr. ij 1 




Ol. amygdal. dulc, 


3ij; 


8 


Tinct. cantharid., 


3ij; 


8 


Spts. vin. rect., 


5y; 


60 


Aq. destill., 


q. s. adf^vj; 


180 



13 



M. 



For this may be substituted J ounce (15.) of resorcin in 2 ounces 
(60.) of alcohol and 6 ounces (180.) of rose-water. 

Sulphur is of great value in the treatment of all sebaceous gland dis- 
orders ; in the form of an ointment, 15 grains (1.) to a drachm (4.) to 
the ounce (30.) of vaseline or other ointment-base, it is often of service. 
One-half the quantity, or as much, of resorcin may often with advan- 
tage be added to the pomade. Sulphur may also be used as a powder, 
either alone or in combination with talc, salicylic acid, boric acid, 
starch, or camphor ; and as a lotion with alcohol, glycerin, and rose- 
or cologne-water. The alterative effect of the mercurials is also as 
evident in seborrhoea as in many other cutaneous disorders. At the 
head of the list, for this special purpose, stands the red mercuric oxide 
in strength of from 2 to 4 grains (0.133-0.266) to the ounce (30.) of 
ointment ; but ammoniated mercury, and calomel in the proportion 
of from 5 to 10 grains (0.333-0.666) to the ounce (30.), may be often 
substituted for the former with advantage. Carbolic, salicylic, and 
boric acids, from 1 to 5 per cent, in alcoholic solutions, with or with- 
out the addition of oil or of glycerin, are often of service. The 
tars are useful in many obstinate cases. Tar-soap may be employed 
in the washing ; or oleum rusci added in the strength of 1 to 10 parts 
to any of the salves recommended above. Ichthyol in ointments of 
the strength of from 5 to 10 per cent, has also proved efficacious. 
Besides these substances, tincture of cantharides, capsicum, and nux 
vomica are frequently incorporated with advantage into lotions and 
pomades for use upon the scalp. Most of the pomades can be rendered 
sufficiently fluent for use in this situation by adding 1 or 2 drachms 
(4.-8.) of glycerin to the ounce (30.) of lard or of cold cream. An 
excellent formula for the scalp is the following : 



B Sulphur, praecipit, 


3j; 


Lanolin., 1 




Glycerin., V 


iia 5ijss ; 


Aq. rosae, J 




Saponis, 


9ss; 


Sig. Ointment for scalp. 




iel recommends : 





151 



R Extra, cinchon. frig, par., ^j ; 1 

Bals. Peruv., gtts. xv ; 1 

Cantharid. tinct., gtts. xxiv-3ss ; 1.5-2 

Succ. citri, n^ xv ; 1 

Ung. pomat., ^jss ; 45 

Sig. To be rubbed into the scalp once or twice daily. 



80 M. 



33 



M. 



Repeated applications and patient care of the scalp are necessary to 
secure complete relief in the case of a disease as essentially chronic as 
seborrhoea. At times the local treatment may be changed with advan- 
tage. Not infrequently too vigorous treatment is followed by a more 
or less acute dermatitis. In this case stimulating preparations should 
be replaced by soothing ointments or lotions until the induced inflam- 
mation has subsided. 

The treatment outlined above for the hairy portions may be used 
with success also for the relief of seborrhoea of the non-hairy portions 
of the body, especially the face. Here, it will be observed, the crusts 
have a tendency to re-form, and the most persistent treatment is nec- 
essary to secure permanent relief. Occasionally, after cleansing the 
surface with soap and spirit-lotions according to the indications of each 
case, it is of advantage to apply the ointment selected for subsequent 
application, not only by gently smearing it on the parts with the tips 
of the fingers (always the most effective method), but also by spreading 
it on a compress, which, for the night at least, may be fixed in contact 
with the part. Unna's lead-plaster mulls, used for this purpose in 
Germany, may fairly well be imitated by drawing strips of cheesecloth 
through heated diachylon ointment and then smoothly smearing them 
with the same material. When the tendency to re-formation of the 
crust is abated one or more of the dusting-powders may at times be 
employed with advantage for the purpose of protecting the skin or of 
exercising upon it an astringent effect. 

Seborrhoea oleosa is best treated with lotions or with powders. 
Should the skin become irritated under these applications, ointments 
may be substituted for a time. Astringent lotions or powders contain- 
ing tannin, gallic acid, zinc sulphate, ferrous sulphate, zinc oxide, 
bismuth subnitrate, etc., are often serviceable. 

The local treatment of seborrhoea of the genitals is somewhat differ- 
ent. Ointments rarely answer well in disorders of the mucous sur- 
faces, and green soap is too irritating for similar employment. Here 
washing with a good toilet-soap and warm water is sufficient for the 
purposes of cleanliness, and diluted lotions containing alcohol, in the 
form of whisky, brandy, or aromatic wine, suffice. These lotions can 
be made astringent with tannin, alum, or zinc sulphate, and when 
there is pain or tenderness opium may be added. In this form of the 
disease, as also in seborrhoea of the umbilicus, carbolic acid or chlori- 



152 DISORDERS OF THE GLANDS. 

nated soda may be necessary to correct fetor. After the employment 
of these lotions boric acid with talc (1 part to 4), or zinc oxide and 
starch (1 part to 8), may be dusted over the part. In the generalized 
varieties of the disease the surface is to be thoroughly anointed with 
oil. The body, especially that of infants, is to be swathed in flannel 
or other good non-conductor of heat, and a roborant treatment directed 
to the general adynamia. 

In the grave forms of seborrhoea of infants (described as keratosis 
sebacea, ichthyosis sebacea, etc.) the body must be kept anointed with 
oils or fats. Artificial feeding is demanded by the condition of the 
mouth. 

Prognosis. — In forming a prognosis in cases of seborrhoea of the 
scalp it must be remembered that the disease is frequently obstinate, 
and shows a decided tendency to recur unless some treatment be con- 
tinued for weeks or months after the scalp is apparently well. The 
resulting loss of hair, if symmetrical, may be remediless, but much 
may be done in the way of saving the hair which is left. Facial 
seborrhoea is much more amenable to treatment; seborrhoea of the 
genitals and the umbilicus is an entirely manageable disease. When 
the affection is generalized the prognosis is in the highest degree un- 
favorable. 

ASTEATOSIS. 

(Gr. a, privative ; oreap, fat.) 

(Xerosis. Ger., Asteatose ; Fr., Asteatose.) 

Asteatosis is that condition of the skin in which there is absolute 
or relative deficiency of the sebaceous secretion. 

Symptoms. — Insufficient lubrication of the skin by its natural 
unguent may be either general or partial, and occur as an idiopathic 
or a symptomatic disorder. It is produced artificially by any agents 
which continually withdraw the fatty substance from the skin-surface, 
as in those trades necessitating the constant immersion of any part of 
the body in strong alkaline solutions or in waters strongly impregnated 
with calcium and potassium salts. As an idiopathic affection it is 
of rare occurrence, but it is not an infrequent accompaniment of 
other local or constitutional diseases, such as psoriasis, lepra, xeroderma 
pigmentosum, ichthyosis, and lichen ruber. In these cases the skin 
becomes dry, often thickened and indurated, and, as a consequence, 
friable, and prone to desquamation, fissures, and chaps. To the touch, 
the absence of sebaceous secretion is noticeable in the objective sensation 
produced. Asteatosis is a well-marked feature of the marasmus of old 
age. Some authors have described under this title the dry thickening 
and induration of the palm of the hand accompanied by curving of 
the fingers toward the plane of their flexor tendons, a condition that 
is occasionally to be observed in laundresses. 

Pathology. — In cases of asteatosis the lumen of the coil-gland is 
commonly dilated, the epithelium is swollen, the loops of the coil 
markedly thickened, and there is produced a compression of the inter- 
tubular connective tissue, as Unna has shown. 



COMEDO. 153 

Treatment. — No internal medicaments are known to have the power 
especially of stimulating the sebaceous secretion. None, indeed, could 
be capable of having such action when, as is often the case in the dis- 
orders characterized by asteatosis, there has resulted an atrophy of the 
sebaceous glands. For external application of an artificial unguent, 
cod-liver oil, almond-oil, lanolin, palm-oil, vaselin, lard, or butter may 
be employed. Vaselin is in many cases to be preferred, as the other 
articles named are liable to become rancid after oxidation, and thus act 
as irritants. Elliott prefers liquid albolene or benzol. With such 
partial or general lubrications, however, a warm bath of soap and 
water should be ordered every second or third day ; immediately 
after the bath the inunction may be repeated. 

Prognosis. — In all cases in which the asteatosis is induced by agents 
operating externally upon the surface a reasonable hope of recovery 
may be entertained after withdrawal of the cause. Persistence of the 
latter is liable to be succeeded by the occurrence of eczema or dermatitis 
medicamentosa. A complete cure can scarcely be expected when this 
condition is a symptom of one of the disorders already named. 



COMEDO. 

(Lat. comedo, spendthrift.) 

(Black-head. Ger., Mitesser; Fr., Acne ponctuee, Acne 

COMEDON.) 

Symptoms. — Comedones are grayish, blackish, yellowish, or other- 
wise colored, dots or points, resembling grains of powder sprinkled 
over the surface of the skin, each point representing the external ex- 
tremity of a plug of inspissated secretion lodged in the excretory duct 
of a sebaceous gland. Comedones, which occur exclusively in the ducts 
of the sebaceous glands, consist each of a whitish fatty plug formed by 
inspissation of the secretion of these glands, one extremity of the plug 
being visible at the surface when it is in situ. Occasionally the come- 
dones project to an appreciable distance above the general level of 
the integument, but often the extremity of each plug is slightly de- 
pressed below that level. There may be but two or three comedones 
upon the face, which is their commonest seat ; or the nose, forehead, 
cheeks, and chin, the front and back of the neck, the back of the 
trunk, and the penis may be studded with them thickly. The visible 
extremity of the comedo varies in size from that of a needle-point to 
that of a pinhead. Comedones are readily expressed from the follicles 
in which they are lodged, and when thus examined they are seen to be 
whitish moulds of inspissated sebum, one or two lines in length, the 
exposed extremity of each comedone having become discolored by 
diffused pigment deposited Avithin. The popular idea that the black- 
head of the comedo is produced by dirt entrapped by the sebaceous 
mass is without foundation. In consequence of this suggestive appear- 
ance of the lesion the disease has been called vulgarly " black-heads " 
and " skin-worms." The deformity produced in the face when these 
lesions exist there in large numbers is strikingly conspicuous, and 



154 DISORDERS OF THE GLANDS. 

it is for the relief of this appearance chiefly that the practitioner is 
consulted. The subjective symptoms awakened are of trifling moment. 
The disorder is essentially chronic in its course. Isolated comedones 
may be observed for years in one situation without apparent change or 
modification of any sort, and without producing the slightest local or 
constitutional derangement. Others appear, only to disappear under 
the influence of the usual hygienic regimen of the skin of the face. 
Others, again, serve to irritate the skin in which they are implanted, 
precisely as though they were foreign bodies ; and the sebaceous glands 
and periglandular tissues, with and without the operation of such cause, 
exhibit grades of hyperemia and inflammation. Comedones may 
occur as the sole lesions of the skin, even to the extent of great 
multiplicity ; or they may coexist with other diseases of the glands, 
chiefly acne. They may occur at any period of life, but, like seborrhoea, 
are most frequently observed at the puberal epoch in both sexes. The 
disease tends to disappear in women earlier than in men, in whose case 
it may be prolonged to the twentieth or thirtieth year. 

Comedones may occur in children, with a special tendency to 
grouping in places subjected to heat and moisture. Recently we have 
recognized them in typical development and considerable number on 
the face of a nursing infant. Crocker was first to notice the fact of 
their occurrence in young subjects. Little reports a case with grouped 
lesions. 1 They also may be found upon the hairy scalp. 

Occasionally a so-called " double " comedo is formed, there being 
expressed from the skin a plug of inspissated sebum, each extremity of 
which is discolored. Whether this double comedo is due to a duplicity 
of efferent ducts in a single gland, or to an artificial or pathological 
connection between two adjacent glands is not clear. 

Grouped Comedones, first described by Thin, 2 are commonly 
found in symmetrical disposition on the cheeks. Crocker, who has 
also contributed to the subject, believes that they may result from 
indigestion. They usually do not coexist with other lesions of acne 
vulgaris. 

Scar-comedones, single, double, and grouped, have been recog- 
nized in the form of atrophy of the follicular orifice (Lang, Selhorst, 
Thibierge). Large and numerous lesions of this type have been re- 
ported after kerion (Crocker), and variola (de Coquet). 

Etiology. — Much has been written with reference to neglect of the 
skin as a cause of comedo, the non-employment of soap in washing 
the face, and the influence of the trades, as in the case of those who 
work in metals, dust, and tar; but observation shows that these are 
exceptional causes. On the one hand, very obstinate and generalized 
lesions occur in the skin of intelligent young men and women of the 
upper social classes, who regularly wash their faces with toilet-soap, 
who are rarely exposed to dust, and whose habits and recreations are 
of the most healthful character. On the other hand, observing the 
grimy faces of coalheavers, machinists, masons, and ink-manufact- 
urers, one is impressed with the rarity of the disease in such laborers. 

1 Brit Jour. Derm., 1903, xv., p. 253. 

2 Lancet, 1888, ii„ p. 712. 



COMEDO. 



155 



Other causes of the constipation of the gland are unquestionably effec- 
tive in most cases. This disorder is somewhat more frequent in thick- 
skinned brunettes, or in men with a characteristic reddish-brown and 
greasy-looking complexion than in individuals having a fair and deli- 
cate skin. 

In many patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of 
the bowels, menstrual derangements, and cachexia. This connection 
is demonstrated by the remarkable improvement manifested in the 
untreated skin when restoration of the general health is assured. 

Fig. 35. 




Section of a comedo : a, excretory duct of a sebaceous gland filled with a comedo ; it con- 
tains also two small hairs with brush-like inferior extremities ; into it opens a small hair- 
follicle (c) ; the contained hair (d), after touching the opposite wall of the duct, curves down- 
ward at /. (After Kaposi.) 

The microbacillus of Unna and Sabouraud may be found, as a rule, 
in the comedo-plug, but whether the bacillus causes or follows the for- 
mation of the comedo is an unsettled question. (See chapter on Sebor- 
rhea.) Acarus folliculorum (see paragraphs under this title) is also 
found in the comedo, but plays no part in the etiology of the disorder. 

Pathology. — Comedo is a dense collection of concentrically arranged 
epithelial cells, in the centre of which are dried sebum, fragments of 
epithelia that have undergone partial fatty transformation, and minute 
lanugo hairs. It is located either in the excretory duct of the seba- 
or in the pouch-shaped canal common to the sebaceous 



ceous gland 



156 DISORDERS OF THE GLANDS. 

gland and the hair-follicle. The first step in its formation is hyper- 
keratosis of the duct produced by some external irritation. In the 
regions in which comedones are found the sebaceous glands are much 
larger than the hair-follicles to which they are attached. In conse- 
quence, as demonstrated by Biesiadecki, the hair-follicles often form 
obtuse or even right angles with the duct of the gland, causing the 
point of the hair to project against and irritate the wall of the duct. 
Unna, Sabouraud, and others believe the external irritation is furnished 
by a definite micro-organism (see Seborrhcea), Sabouraud claiming that 
comedo is always preceded by oily seborrhcea. The blackness of the 
head of a comedo may be due in part to accumulation of dust or dirt, 
but is owing chiefly to a definite pigment which extends for some dis- 
tance below the exterior face of the plug. This pigment is soluble in 
concentrated nitric or hydrochloric acid, and in hydrogen peroxide. 

Diagnosis. — The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 
identify the affection, though frequently misled as to the character of 
the " skin-worm." It is, as might be expected, a frequent coincident 
of acne ; its lesions, when commingled with those of the disease last 
named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
comedo may be produced upon the face when tar or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various points upon the 
skin, often at the orifices of the sebaceous glands. 

Treatment. — The internal treatment of patients affected with 
comedo is that described in connection with the subject of sebor- 
rhcea. Cod-liver oil, iron, the bitter tonics, and the medicaments in- 
dicated by any special condition of the patient's health are not to be 
omitted. Open-air exercise, daily cool salt-and-water bathing, as in 
the management of seborrhcea, and the avoidance of all medicinal and 
dietary articles which might tend to aggravate the disorder, are also 
imperative. Many of these patients require at the outset alterative 
cathartics, among which may be named the pill of blue mass (taken for 
ten or more consecutive evenings, and followed by the effervescing 
sodium phosphate in the morning), calomel, cascara sagrada, and 
castor-oil. 

Even aggravated cases of comedo are completely relieved when 
untreated in the course of time. The relief, however, may require 
years for completion. The rarity of comedones in middle life and 
advanced years sufficiently attests this fact. Presumably this natural 
cure is due to more vigorous groAvth of lanugo-hairs with the increment 
of age, which thus push slowly forward to the surface the excrementi- 
tious mass, until it is gradually removed by ordinary friction and ablu- 
tion. Absence of comedones from the scalp, with a few marked excep- 
tions, where the hair is vigorous, is certainly a significant fact. 

Comedones are removed artificially with the aid of an extractor. 
The instrument formerly employed for this purpose was shaped like a 
watch-key, the cylinder having a smooth bore and bevelled extremity. 
This clumsy tool is far surpassed by the exceedingly convenient comedo- 



COMEDO. 157 

extractor designed by Unna and modified by Piffard. Eacli end has 
a convex, bowl-like surface, with apertures cut to gauge and the orifices 
slightly countersunk. This extractor, " presser," is productive of far 
less pain to the patient than other instruments, and can be wielded, on 
account of its long shank, with greater precision and ease by the physi- 
cian. The surface to be operated upon is previously moistened by 
spraying it with a solution of formalin (0.5 per cent.), of borolyptel, 
of thymol and glycerin, or of eucalyptol and glycerin. Often a sharp- 
edged or well-rounded needle, firmly held in a needle-holder, mzy 
advantageously be employed alternately with the extractor, in opening 
certain follicles or loosening the plug of others. Many patients affected 
with comedo are advantageously treated by the aid of the massering- 
ball, described in the chapter on the management of Acne. All these 
instruments should be disinfected scrupulously before use. The dan- 
ger of such manipulations should never be overlooked. There are good 
reasons for selecting the hour before sleep as the time for all vigorous 
topical applications to the face. Ointments then applied can be left in 
contact with the skin during the night, and the patient be at liberty to 
resume his usual vocation in the daytime, his face being free from con- 
spicuous evidence of local treatment. 

An ordinary watch-key, a curette, the thumb-nail, or a spatula may 
also, on occasion, be used in the extraction o£ comedones, which, if 
few, may be expressed at one sitting, or, if numerous, be removed on 
separate occasions. Repetition of the process is usually required 
owing to re-formation of the plugs. 

Once the comedones are removed the skin should be sponged and 
bathed with hot water, then thoroughly dried, and anointed with an 
ointment which may be medicated to suit the indications of each case. 
Sulphur, as in many disorders of the sebaceous glands, enjoys here a high 
reputation. In the strength of 10 grains (0.66) to 1 drachm (4.) to the 
ounce (30.) of cold cream or vaselin, it may be applied as an ointment ; 
or as a lotion, in combination with spirit of wine, glycerin, etc. A 
useful application is suggested by Piffard — equal parts of sublimed 
sulphur, alcohol, compound tincture of lavender, glycerin, and camphor- 
water. 

Mercurials are also of some advantage locally, but should not be 
employed at the same time with preparations of sulphur. The use at 
night, especially in obstinate cases, of the white-precipitate ointment, 
or of one compounded of 2 grains (0.133) of the red oxide to the ounce 
(30.) of cold-cream salve, will often prove of benefit. In the case of 
coarser skins, corrosive sublimate, 1 to 2 grains (0.066 to 0.133) to the 
ounce (30.) of glycerin and rose-water, may be substituted for the red- 
oxide ointment. 

When extraction of the plug is not attempted nor permitted, some- 
thing may yet be done to remove the inspissated mass. Repeated 
sponging every third night with 1 ounce (30.) of green soap, digested 
in an equal quantity of cologne-water, will at first seem to render the 
comedo more conspicuous, but will slowly operate to dissolve the 
sebaceous secretion. 

An ointment containing 4 parts of kaolin, 3 of glycerin, and 2 



158 DISORDERS OF THE GLANDS. 

of acetic acid, with or without the addition of a small quantity of 
ethereal oil, may be applied at night for a few nights in succession, 
the eyes being carefully protected, when the black points of the lesions 
are removed, and the comedones are then readily extracted. Citric or 
dilute hydrochloric acid is employed with the same end in view. 
These topical remedies cannot be considered as efficient in every form 
of comedo. 

Actors, actresses, and women of fashion will, while under treatment, 
occasionally persist in using various colored toilet-powders, the inju- 
rious ingredients of which are often the cause of the disease. The 
practitioner may then either refuse to be responsible for the care of the 
case, may substitute a harmless for a noxious powder, or may gently 
anoint the face after his treatment of it with a bland ointment or the 
Lassar paste, upon the surface of which the theatrical eifects are sub- 
sequently produced. In such cases the use of soap and water with each 
dressing is more than usually imperative. 

Comedones of the penis need not be treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with singular alarm. 

Prognosis. — As the disease naturally tends to spontaneous though 
occasionally long-deferred resolution, the prognosis is favorable. Treat- 
ment in most cases will accomplish much in hastening the disappear- 
ance of the comedones. The most obstinate forms are those in which 
the face, the back of the ears, the inside of the auricle, the neck, and 
the shoulders are studded with relatively small indolent comedo-points, 
about which the circular lip of the duct rises in a whitish rim. This 
rim, when felt with the finger, produces the impression of hyperplasia 
of the wall of the duct. Such cases, however, are nearly allied to the 
forms of acne described elsewhere. With exceeding rarity, the comedo 
is merely the introduction to a more serious local affection. In early life 
a single prominent lesion is formed, and though the plug be frequently 
removed and finally be no longer reproduced, the orifice of the duct 
remains patulous in middle life. Slowly thereafter its walls undergo a 
metamorphosis and a warty epithelioma may result. 

MILIUM. 

(Lat. milium, a millet-seed.) 

(Grutum, Strophulus Albidus, Tuberculum Sebaceum, Acne 
Albida. Ft. Acne miliaire.) 

Symptoms. — Milia occur upon and about the eyelids, the cheeks, 
the forehead, the temples ; the penis, scrotum, and corona glandis of 
men ; and the internal face of the labia minora of women. They are 
millet-seed- to pinhead-sized, pearly-white, occasionally symmetrical 
by placed, globoid masses, rarely attaining the dimensions of a coffee- 
bean, showing within the epidermis as though kernels of rice were 
lying there immediately beneath a translucent layer of tissue. They 
occasionally project from the surface to such an extent as to resemble 
small-sized vesicles having milky contents. In color they are yellowish 



MILIUM. 159 

and whitish. They are often congenital, and can be recognized about 
the lids and temples of the newborn infant ; they are also seen, how- 
ever, in middle life, when they develop very slowly, and sometimes 
persist for years. They are often observed in the neighborhood of 
cicatrices, which in such cases have usually been effective in their 
production. They occasion no subjective sensation, and are commonly 
so insignificant as to induce no deformity. They never degenerate 
by ulcerative processes, but when not artificially removed, in the 
course of years are exfoliated in the natural processes of physiological 
desquamation. In rare instances the deposit within the milium tumor 
of the salts of lime renders them as hard as cartilage (Cutaneous Calculi). 
They are usually larger than the small-sized milia and of a more yel- 
lowish hue. 

Etiology. — Milia may be of embryonic origin and occur in the 
newborn ; they are common in infancy and early adult life, and are 
rare in middle life, though occasionally developing after the thirtieth 
year. They are at times produced mechanically ; the stroke of a knife- 
blade, accidentally or in the processes of surgery, separating one or 
more of the acini of a sebaceous gland from the main body. The con- 
tracting bands of a cicatrix, after destruction of tissue from any cause, 
may operate in a similar way with precisely the same result, and they 
may thus follow the lesions of tuberculosis, syphilis, erysipelas, and 
pemphigus vegetans. 

Pathology. — When a milium is incised externally a spherical body 
of nearly corresponding size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attachment 
to the hair-follicle. The small mass thus extracted is seen to be a 
horny cyst composed of several thin envelopes, suggesting the capsules 
of the onion and representing cornified epithelia which have not under- 
gone fatty metamorphosis, and in the centre of which is a fatty nucleus. 
There is never any lobular formation. Each of these horny cysts is 
developed in connection with the lanugo hair- follicles, distending the 
latter, as Unna has shown, irregularly and on one side. The process 
represents a hyperkeratosis of the epithelium of the hair-follicles, 
though it is believed by some that the milium represents a retention- 
product of the sebaceous glands. 

The epithelia from which the contents of milia are produced at 
times tend to develop into horny or other formations. Thus, Foster, 
of Boston, describes a case in which the process of calcification had 
apparently been complete ; Wagner observed colloid contents in cer- 
tain opalescent lesions which appeared on the cheeks and temples of a 
woman ; Barensprung and Hebra report numbers of acutely produced 
milia following pemphigus and erysipelas ; and Virchow and Rind- 
fleisch describe milia of the hair-sacs and similar lesions accompanied 
by cysts of the adjacent hair-follicles. In some cases the cause of 
milia is to be sought in obscure changes by which the epithelia of the 
follicle are primarily aifected. 

Robinson believes that milia originate from miscarried embryonic 
epithelia from hair-follicles or from the mucous layer of the epidermis. 

Diagnosis. — Milia might be mistaken for minute vesicles containing 



160 DISORDERS OF THE GLANDS. 

a milky fluid, but puncture of the lesion, with expulsion of its contents, 
at once discloses their character. Comedones with blackish external 
points, surrounded by the patulous orifice of the excretory duct and 
prolonged more deeply into the substance of the skin, could scarcely be 
confounded with milia. 

The most minute of the lesions of xanthoma have a yellowish color, and 
cannot as readily be scraped away from the subjacent tissue as can milia. 

Treatment, — Milia rarely require treatment, as they are usually 
relatively few in number, and produce neither subjective sensation nor 
deformity. If desired, they may be opened with a fine milium-needle 
and their contents turned out, or they may be scraped off with a 
curette. To insure their non-recurrence, the little sac left after the 
operation may be entered with a needle which has been dipped in a 50 
per cent, solution of chromic acid. This operation may have to be re- 
peated in the rare cases in which the lesions exhibit a tendency to recur. 

The simplest and most elegant method of removing these and many 
similar-sized lesions of the skin is by the galvanic battery. With from 
four to six cells in the circuit the negative pole is connected with a 
fine needle, which is introduced within and beneath the lesion, while 
the moistened sponge of the positive pole is in contact with the skin of 
the patient. This operation is bloodless and effectual, insignificant 
scars resulting. 

The Prognosis is always favorable. 

Milium Congenitale (en plaques) has been described by Crocker, 1 
Hans Hebra, Wilson, and Fox, as a congenital condition in which occurs 
a reddish-yellow patch (destitute of hair when existing on the scalp) 
with well-defined border and a granular surface, constituted of minute 
yellowish papules, with comedones at the periphery and elsewhere. 

Hypertrophy of the Sebaceous Glands, characterized by 
actual multiplication of the glandular acini, is described by Crocker 2 
as of occurrence on the forehead, nose, and other parts of the face of 
the aged, often accompanied by minute disks of a light-yellowish or 
dirty-yellowish shade, having a central punctum corresponding to the 
opening of the duct. In other cases discrete nodules occur. The 
author cited has noted their concurrence with jaundice and general 
xanthoma. In one case pinhead- to hemp-seed-sized opaque and 
sometimes superficially vascularized papules with depressed centres 
formed ; the smaller were semitranslucent ; some contained a central 
plug that could not be expressed. 

We have observed this condition in two middle-aged women in 
good health. The lesions in both instances were scattered singly or 
in groups of three or four over the face. Some of the lesions suggested 
strongly those of molluscum contagiosum. In some the disk was 
apparently made up of three or four pin-head-sized lobules coalescing 
about a depressed follicular opening which was not always centrally 
situated. We have seen the condition also preceding the development 
of superficial epithelioma, and also when existing on the face with 
1 Diseases of the Skin, p. 1131. 2 Ibid., p. 1131. 



STEATOMA. 161 

development of similar lesions upon the backs of the hands distinctly 
epitheliomatous in type. 

Pollitzer l reports a case of this type in which the lesions were 
arranged in a double row, about an inch and a half long, on the fore- 
head above the left eyebrow. As the result of histological examina- 
tion, Pollitzer reported the case as one of adenoma sebaceum, although 
clinically it did not correspond to the cases usually included under 
that title. On the other hand, Marrullo, 2 Whitfield, 3 and others find 
that the cases which clinically are known as adenoma sebaceum, show 
histologically an hypertrophy and not the structure of adenoma. 

STEATOMA. 

(Gr. G-eap, fat.) 

(Wen, Pseudo-atheroma, Sebaceous Cysts, Sebaceous Tumor. 
Fr., Steatome, Kyste sebacee; Ger., Balggeschwulst, 
Grutzbeutel.) 

Symptoms. — The history of the development and career of wens 
does not greatly differ from that of milia. Wens are usually of slow 
growth ; unattended by subjective sensation ; occur as single or multiple, 
elevated, occasionally flattened, fixed or movable tumors on the head, 
the trunk, or the genitals ; and, being larger than milia, may attain 
the size of a hen's egg. Centrally or laterally placed is seen usually 
on the surface of each a patulous orifice closed with a blackened horny 
plug suggesting a giant-comedo. They are situated beneath, within, 
or upon the skin ; usually are unattached to the deeper contiguous 
tissues ; and develop into irregularly globular, occasionally large button- 
shaped masses, covered by an integument usually unprovided with 
hairs. This- envelope may be normal in hue, or unnaturally whitish 
from pressure ; or, especially upon the bald scalp of certain fleshy men 
of middle years, reddened, shining, and greasy in appearance. Their 
semisolid cheesy and milky contents often emit a nauseous odor. At 
times the cysts are to be distinguished only by passing the fingers 
through the long hairs of the scalp beneath which they are hidden ; at 
other times they are so conspicuous in consequence of physiological 
alopecia as to occasion considerable disfigurement. They vary greatly 
in consistence, but usually produce to the touch a certain feeling of 
elasticity, especially if the cyst be distended tensely. They may per- 
sist for years without producing inconvenience save that resulting from 
their bulk and the consequent disfigurement, but may be attacked by 
inflammation, resulting in suppuration and ulceration. 

Cysts (Sudoriparous Fat-cysts [Dubreuilh] ) of the steatoma- 
type may be single or multiple and numerous. Maclaren 4 reports the 
case of a lad, nineteen years of age, having tumors of this sort over 
the entire body-surface : they resembled fibromata, but were found on 
examination to be sebaceous in character. Dubreuilh, Auche, and 

1 Jour. Cutan. Dis., 1893, xi., p. 475 (with clinical and histological illustrations). 

2 Zeitschrft, 1902, be., p. 166 (with bibliography), 

3 Brit, Jour. Derm., 1902, xiv., p. 326. 

4 Brit. Med. Jour., October, 1886. 

11 



162 DISORDERS OF THE GLANDS. 

Chiari have reported similar cases in which pin-head- to pea-sized, firm, 
well-rounded lesions subcutaneous in situation, but at times projected 
from the surface, had either the color of normal skin or were grayish- 
yellow in hue, occurring about the axillae, the scalp, the extremities, 
or generally over the trunk. They contained a semifluid material, and 
were found to be thin-walled cysts with a tenuous envelope, epithelium- 
lined, derived originally from the coil-glands. We have had under 
observation a young woman the upper part of whose chest was covered 
thickly with pin-head-sized and somewhat larger retention-cysts cov- 
ered with normal skin, the contents of which were wholly sebaceous. 

Chalazion is a term descriptive of pin-head- to small-nut-sized 
tumors occurring in relation with the Meibomian follicles. They were 
thought once to be of sebaceous origin, but are now recognized as 
benignant new growths. A fungus supposed to be pathogenic has 
been recognized by Weyman. 

Pathology. — Wens represent distention of the sebaceous glands by 
their contents, and response to the constant pressure in hypertrophy of 
the glandular envelope. Their contents, which are semisolid, curdy, 
cheesy, and granular, fluid and milky, or fluid and purulent, are the in- 
spissated or chemically altered products of the gland-secretion, recogniza- 
ble as such by the materials of which they are composed — masses of fat 
and debris of epithelia, with an occasional lanugo- or undeveloped hair. 

In some cases wens are more than mere retention-cysts, a benign 
new-growth of connective tissue forming the mass of the tumor. Cal- 
careous and atheromatous changes in the contents of the cyst are 
common. Torok, Chiari, and others claim that the majority of these 
growths are really dermoid cysts. Torok found a true papillary body 
in the walls of many of these cysts, and states, furthermore, that such 
cysts contained no fat. 

Diagnosis. — Steatomata are to be distinguished from true athero- 
mata in that the latter exhibit no opening, never have odorous contents, 
always originate in the hypoderm, and frequently occur in portions of 
the skin other than the scalp. Steatomata are also to be distinguished 
from fatty tumors, which, however, are observed more commonly about 
the scapulse, loins, buttocks, and extremities ; while wens are very rarely 
found except about the scalp and neck ; they lack also the peculiar 
" pillowy " feel of fatty tumors. Suppurating wens in the regions 
named may readily be mistaken for circumscribed abscesses if regard 
be not had for the history of the tumor usually long preceding. 
Syphilitic nodes and gummata of the same parts are usually both 
tender and painful ; osteomata also are attached firmly. 

Treatment. — The removal of a wen is accomplished by excision, 
after previous puncture of the sac and removal of its contents. 

With antiseptic precautions ablation of these lesions from any 
part of the body may be regarded as unattended with great risk. 
Several fatal cases, however, are on record as the result of this opera- 
tion, due not so much to the nature of the excised tumor as to its 
situation, surgical wounds of the scalp being particularly liable to 
erysipelatous and other complications. As the incision required for 



STEATOMA. 163 

the removal of the wen necessarily must extend some distance on 
either side of the tumor, there results a linear scar, which on the bald 
scalp is often a very conspicuous relic of the lesion. In consequence 
of the possibility of danger many surgeons prefer destruction of a 
prominent section of the mass with acid or alkali, leaving the sac, after 
expulsion of its contents, to wither gradually, though it may then be 
often withdrawn with forceps. 

Complete obliteration is sometimes effected by puncture, expression 
of the contents, and subsequent induction of artificial inflammation in the 
walls of the cyst by injection of tincture of iodine, pure sulphuric ether, 
or other irritating fluid, as in the operation for relief of hydrocele. 

Prognosis. — The removal of the wall of the cyst is not followed by 
a return of the lesion. In debilitated and cachectic patients there may 
be spontaneous ulceration and sloughing, with or without surgical in- 
terference. Mr. Thomas Bryant 1 reports a carcinomatous tumor 
following the removal of a steatoma from the buttock of a woman 
sixty-three years of age. 

Congenital Fibro-sebaceous Disease. — Crocker reports two 
instances occurring in infants who at birth exhibited signs of the 
disease, in which patches with an area of " several square inches " were 
visible on the face, the front of the neck, and in front of and above 
the ear. These patches were slightly raised, of a pale reddish-yellow 
color, finely granular over the surface, and consisted of closely aggre- 
gated, pale-yellowish, pin-point-sized papules, the patches being sharply 
defined with many comedones at the borders. These growths, on sec- 
tion, seemed to be due to a fibrous hypertrophy resulting in atrophy 
of the hair-follicles and coil-glands, and separation of the lobes of the 
sebaceous glands. 

Sebaceous Cystic Disease is reported by Cook, Hutchinson, and 
others, in cases in which steatomata in typical situations resulted in 
ulcerations of malignant type; in still other cases fungous tumors of 
considerable size formed, requiring surgical attention. 

1 Brit. Med. Jour., 1884, i., p. 1044. 



CLASS II. 
INFLAMMATIONS 



EXANTHEMATA. 

(Gr. etjdvdqfia, blossoming, flowering.) 

Foe a detailed consideration of the phenomena of the exanthematous 
fevers the reader is referred to the standard treatises on the subject 
in the field of general medicine. Space is allotted here merely to a 
description of the cutaneous lesions by which they are severally char- 
acterized. These are unlike in each disease, yet all exhibit certain 
common characteristics. In all the eruptions are symmetrical, and in 
typical cases are general. In each the efflorescence is succeeded by a 
desquamative or exfoliating condition of the skin. In each there is, 
within relatively fixed limits, a distinct stadium of the pathological 
process within which it is completed, and beyond which, however per- 
sistent may be its remote sequelae, there is no chronic manifestation 
of the disorder. Each, also, is produced solely by its specific con- 
tagium, derived exclusively from an animal body affected with the same 
disease, being never, so far as known, generated from any other source, 
nor merging by imperceptible degrees the one into another. Two of 
these may rarely concur, but under such circumstances the one is 
always more pronounced in its features, which either closely precede or 
follow those of another. No specific medication is known to be capable 
of arresting any one of them, each pursuing its course uninterruptedly 
to a favorable or a fatal termination, according to the intensity of the 
poison present in each case and to the more or less favorable or unfavor- 
able conditions of the sufferer. Finally, it is probable, though not at 
present demonstrable, that specific micro-organisms are etiological 
factors in the production of each. 

RUBEOLA. 

(Measles, Moebilli. Ger., Maseen, Fleck en ; Fr., Rougeole ; 
ItaL, Rosolia ; Sp., Serampion.) 

The objective symptoms of this disease are preceded by a period 
of incubation lasting from eight to twenty-one (usually between twelve 
and fifteen) days, a period in which there may be no evidence of ill 
health, or merely a moderate degree of lassitude and inappetence. To 
this period succeeds a prodromic fever, the temperature rising to 
102°-104° F., occasionally alternating with chills or a sensation of 
chilliness, dryness of the skin, pains in the head, thirst, occasionally 

165 



166 INFLAMMATIONS. 

sweating, rarely convulsions in children, and almost invariably a 
serous catarrh of the mucous surfaces, with specially pronounced ocular, 
nasal, pharyngeal, and laryngeal phenomena. By the second or third 
day the temperature begins to decline, while the catarrhal symptoms 
increase, these being manifested in sneezing, a copious secretion from 
the eyes and nose, and engorgement of the exposed mucous surfaces, 
especially of the conjunctivae, the nares, and the throat. Occasionally 
the tongue and the fauces exhibit a few closely set, isolated, minute 
reddish puncta (enanthem). In consequence of the implication of the 
larynx, the trachea, and ultimately the larger bronchi, there is a hoarse, 
frequently an incessant and teasing cough of a convulsive character, 
accompanied by expectoration of mucus and muco-pus in moderate 
quantity. This prodromic period lasts from three to five days, but in 
exceptional cases is prolonged to twice that length of time. Upon its 
conclusion the exanthem appears, usually on the fourth day, Avith aggra- 
vation of the fever, the temperature rising to 104°-106° F., and re- 
maining at that point until the eruption has reached its apogee, when it 
commonly declines pari passu with the severity of the skin-symptoms. 

Koplik's 1 diagnostic early sign of measles is the development on 
the mucous membrane of the palate, uvula, lips, and cheeks, of nearly 
90 per cent, of cases often as early as seventy-two hours before the 
appearance of a characteristic exanthem, of pin-head- to split-pea- 
sized bluish-white glistening spots or of brilliantly red patches with a 
bluish-white punctum centrally situated in each. The occurrence of 
this early sign of the disease has been corroborated by other observers. 2 
Period of Efflorescence. — The eruption of measles usually appears on 
the morning of the fourth day first upon the face (the forehead and 
temples), and thence extends in about thirty hours over the neck, the 
upper portion of the trunk, and the superior extremities. Between the 
fourth and sixth day of the disease it usually attains its deepest shades 
of color and its maximum of development over the entire surface of 
the body, including the palms and the soles. This maximum attained, 
the eruption gradually fades ; the tumid condition of the skin, most 
noticeable on the face, also subsides ; the catarrhal symptoms and 
cough become less annoying ; and the patient enters upon the period 
of desquamation. 

The eruption is almost invariably symmetrical, and is characterized 
by the occurrence of a diffuse reddish, yellowish-red, mulberry-red, 
deep raspberry-red, or, in extreme cases, violaceous-tinted coloration 
of the skin, or of pea- to small finger-nail-sized (a millimetre to a 
centimetre in diameter) oval, round, or irregularly shaped, fairly well- 
defined macules, either not elevated or very slightly raised above the 
general level of the integument ; or by the occurrence of large pin- 
head-sized, discrete papules, much more rarely pin-point-sized vesicles, 
corresponding in color with the shades described above, and highly 
suggestive of the first efflorescence in variola. These lesions become 

1 Arch, of Pfediat, 1896, xiii., p. 918; N. Y. Med. Kecord, 1898, liii., p. 505. 

2 Filatou, Acute Infectionskrank., 1895; Weiss, Wien. klin. Wchnschrft., 1899, xii., 
p. 683 (abstr. in Brit. Jour. Derm., 1900, xii., p. 33) ; Williams, Bristol Med. and Chir. 
Jour., 1900, xviii., p. 139 (abstr. in Brit. Jour. Derm. 1900, xii., p. 331.) 



RUBEOLA. 167 

pale under pressure, exhibiting then a yellowish tint, and often are set 
together closely, particularly over the upper segment of the body, in 
patches suggesting a crescen tic outline. The term "suggesting" is used 
here purposely, as it is difficult, by selecting a single patch, to determine 
by the eye alone the existence of such a configuration ; while an exami- 
nation of the eruption as a whole may often very clearly convey this 
impression to the sight. Usually, patches of sound skin can be recog- 
nized even when the eruption appears to be confluent, complete con- 
fluence never occurring so as to form a sheet or mask over the entire 
skin-surface. Individual lesions may so merge as to be well-nigh 
indistinguishable separately ; yet, on the whole, the eruption deserves 
fully the plural character of its English name. It is made up in all 
cases of innumerable elements, whose identity is never wholly lost. 
The subjective sensation awakened is occasionally a severe itching or 
burning ; frequently this is an insignificant matter compared with other 
disagreeable symptoms — the cough, coryza, and fever. 

The exanthem spreads from the face to the upper extremities on the 
second day, and over the lower limbs on the third day of the rash. Its 
complex expression usually coincides with decided aggravation of the 
catarrhal symptoms. 

Period of Desquamation. — The decline of the disease is accom- 
plished usually with cessation of fever and the production of delicate 
yellowish-brown pigmentations of the surface where the elements of 
the eruption have existed, involution being manifested first in the site 
of the lesions which were earliest to develop. The scaling when 
present is usually of moderate grade. Gradually and simultaneously 
the catarrhal symptoms of the respiratory passages diminish in severity. 
This final stage of the disease in favorable cases usually is terminated 
in a fortnight from the date of invasion. 

The complications and anomalies of measles depend upon the intens- 
ity of the poison, displayed in the most formidable symptoms where 
human beings are crowded together, as in camps and prisons ; upon 
the degree of physical vigor ; and also upon the various hygienic sur- 
roundings of the victims of the disease. Thus, the period of efflores- 
cence may be unusually prolonged ; the eruption may disappear 
suddenly, and as rapidly reappear; the cutaneous symptoms may alone 
be wanting ; the latter may be commingled with petechia due to 
cutaneous extravasation of blood, which may also be accompanied by 
severe epistaxis ; and the catarrhal condition of the mucous surfaces 
affected may terminate in croupal or in diphtheritic disease, may be 
followed by capillary bronchitis, catarrhal pneumonia, and even by 
pulmonary tuberculosis. Typhoid conditions may also supervene, and 
chronic inflammatory affections of the eyes and of the Schneiderian 
membrane result. Measles, scarlet fever, and other exanthemata may 
concur. 1 

Etiology. — The disease is infectious and contagious, being com- 
municable from person to person, the virus being transmitted less 
readily by the medium of fomites than in other exanthemata, and 

1 Williams, " Rubeola, Scarlatina, and Fourth Disease," Brit. Med. Jour., 1901, ii., 
p. 1797. 



168 INFLAMMATIONS. 

usually rendered innocuous by exposure to sunlight and air. The 
malady is believed to be infectious in all stages even before that of 
eruption ; and the effective agent is present in the blood as shown by 
inoculation-experiments during the prodromal stage. Susceptibility, 
save in those protected by previous infection, is general, though second 
attacks of the disease are on record, the most of such, however, being 
open to suspicion, since roseola (German measles) may follow rubeola. 
In the human family all ages and both sexes are liable to contract the 
disorder, and it is believed that animals are not exempt. 

The Pathology of the cutaneous lesions in measles is that merely 
of acute hyperemia occasionally passing into exudation, limited for the 
most part to the vascular papillae of the corium and the perifollicular 
plexuses of blood-vessels. There is oedema of the fatty tissue surround- 
ing the coil-glands, in the sheaths of the larger vessels, the cutaneous 
muscles, and the hair-follicles. The coils, follicles, and muscles seem 
to swim free in widely dilated spaces. There is no cellular exudation 
and no mitosis (Unna). Post mortem the eruption fades, as the result 
of gravitation of the blood from the anterior aspect of the body as it 
reclines upon the dorsum. 

Bacteria of small size and remarkable motility have been found in 
the blood by Coze and Feltz ; micrococci in the trachea by Klebs ; 
spherical bodies in the breath of children, and post mortem in the 
lungs and liver by Braidwood and Vacher ; and similar organisms in 
the vesicles and pustules of malignant measles by Keating and 
Formad. 1 Lesage, 2 studying the disease in 200 cases, often cultivating 
a delicate micrococcus on gelose, reports a production of something 
like the disease by inoculation. 

The disease is chiefly one of infancy, probably because at that age 
there is always the largest number of individuals unprotected by pre- 
vious attacks. In every case the malady results from contagion, medi- 
ate or immediate, from an infected human subject. It spares neither 
age nor sex, though it is much rarer in advanced years than at other 
periods of life, probably because of the large number who at such 
period enjoy immunity. 

The Diagnosis of importance is between scarlatina and variola. 
Typical cases with a well-developed eruption can scarcely be mistaken 
if the symptoms displayed are assigned their full weight. It would 
be useless, however, to deny the fact that atypical forms occur which 
have confused the most expert diagnosticians ; in all cases of doubt the 
prudent practitioner will refuse to decide as to the nature of the dis- 
ease until unmistakable symptoms, in the lapse of time, have been 
declared. The resemblance between ill-developed measles and certain 
of the eruptions seen in varioloid is striking, and the greatest skill, at 
a given moment of time, will in cases fail to make a decision between 
the two. A distinctly crescentic character of the eruption, the preva- 
lence of an epidemic, the discovery of Koplik's spots, the presence of 
catarrhal symptoms, the continuance of fever after the efflorescence is 
completed, the color of the eruption, and the discovery of the nature 

1 Cf. Canon and Pielicke, Sternberg's Magnan's Bacteria, New York, 1884. 

2 Bull, de la Soc. med. des Hopit. de Paris, March 15-20, 1900, 3 s., xvii., p. 282. 



ROTHELN. 169 

of the disease from which the contagion was derived, all point to the 
truth. From scarlatina measles is differentiated much more readily by 
the macular or papular elements of its eruption ; by their cyanotic, 
darker hue ; by their appearance to a marked degree upon the face ; 
and by the absence of the characteristic sore throat, tenderness of the 
neck, and characteristic " strawberry tongue," and usually intense 
febrile access of the first-named disease. From the various forms of 
erythema accompanied by fever, as well as from the medicinal rashes, 
insect-bites, and syphilitic eruptions, measles can . be distinguished by 
the irregular temperature-record as well as by the character of the 
eruption. The diagnosis between rubeola and rotheln is given later. 

The Treatment of measles should strictly be limited to careful 
hygienic attention to the invalid, including a restricted u fever diet," and 
to the strictest isolation, disinfection, and ventilation, and to the use of 
only such medicaments as especially are indicated. The antithermic 
remedies employed in the general management of the febrile process 
may be required in special cases. 

In the way of local treatment the skin should be anointed with a 
bland, oily, or fatty substance, to relieve the pruritic sensations, espe- 
cially after sponging of the surface once daily with a weak alkaline 
solution, which may be used cool without fear of producing " reper- 
cussion " of the exanthem. The chamber of the invalid should be 
somewhat darkened for the sake of the eyes, but pure air should con- 
stantly be admitted. 

The Prognosis is in general favorable, but is of the gravest in special 
conditions. All the complications named above increase the gravity 
of the disease, which is also enhanced among men crowded together in 
camps, children in public charities, pregnant women, the cachectic and 
those greatly enfeebled from disease, very young infants, old men and 
women, and residents of islands that have been long unvisited by epi- 
demics of the malady. 

The disease has been demonstrated to produce itself by contagion 
two to four days before the appearance of the rash, while the capability 
of transmission is usually lost between the twentieth and the thirtieth 
day after the exanthem is fully developed. 

ROTHELN. 

(Rubeola, Rubeola Notha, Rubella, German Measles, Hy- 
brid or Bastard Measles, French Measles, Epidemic 
Roseola. F>\, Rubeole ; Ger., Rotheln.) 

Symptoms. — This is a contagious disease which has an incubative 
period lasting from a few hours to twenty-one days, followed either 
by the eruption or by prodromes lasting for a few hours to a 
single day. These symptoms are malaise, cephalalgia, articular pains, 
anorexia, and nausea. The occipital, cervical, and other glands may 
at this time become large and tender. After a pyrexic period, rarely 
lasting longer than a few hours and in many cases absent, the eruption 
appears, occurring for the most part in the regions affected by measles, 



170 INFLAMMATIONS. 

first on the face and scalp, later on the neck, the trunk, the upper and 
finally the lower extremities, in the form of multiple, discrete, pin- 
point- to small pin-head-sized macules, but smaller than the lesions 
displayed in that disease, and decidedly lighter in color. The shade 
is from a rosy or pinkish to a crimson red, rarely lurid, never of dark 
mulberry or violaceous hue. This color at times will be perceptible 
beyond the line of the lesions as a delicate halo, a circumstance which 
strongly distinguishes the exanthem from morbilli. The lesions, more- 
over, seldom are arranged in crescentic outline, more often being 
grouped in roundish or oval patches. Often, indeed, the elements of 
the eruption are discrete and disseminated, and after complete evolu- 
tion may be elevated slightly above the general surface. The fauces 
occasionally are reddened in puncta. The eruption commonly fades in 
from a few hours to one to two days, and there may be slight resulting 
cutaneous desquamation. 

The rash of rotheln is to be distinguished from that of measles by 
the recognition of the features described above, particularly by the 
color, contour, and date of occurrence of the exanthem ; the transitory 
character of the fever when the latter is present ; the cervical adenop- 
athy ; and the rapidity with which involution of the disease progresses. 
By the temperature-record alone of the patient it may be differenti- 
ated from scarlatina, though the rashes are dissimilar in the two dis- 
eases. It is also not to be confounded with the erythematous affec- 
tions of the skin. One of the most striking characteristics of the disease 
can be best recognized in a ward filled with children, all of whom are 
simultaneously affected with the disorder. That characteristic is the 
remarkable mildness of the phenomena displayed in every case. 

Etiology and Pathology. — The disease occurs in epidemic form, 
is distinctly infectious and contagious, attacks an individual but once 
in a lifetime, affords no immunity in subsequent exposure to either 
measles or scarlatina, and attacks usually young subjects. 

Diagnosis. — While the symptoms of rotheln are so defined as to 
justify a reasonable certainty in its diagnosis, it is now generally 
accepted that the malady exhibits no characteristics that may not be 
exhibited in measles. The characters of the exanthem seen in any 
case, the adenopathy when this is present, the occurrence of the disease 
in young subjects who previously have suffered from measles, and the 
evanescent lesions of the skin, with the absence of a typical coryza, 
are all suggestive. By some observers the identity of the affection, 
as distinguished from all others, has been called in question. 1 

Treatment. — Rotheln should be treated by rest in bed, an abun- 
dant supply of fresh air, strict asepsis, and the usual diet of fever- 
patients. Medication by drugs rarely is indicated. 

1 Dilingham, Amer. Med., 1903, vi., p. 263; Griffith, Phila. Med. Jour., 1902, ix., 
p. 659. 



SCARLATINA. 171 

SCARLATINA. 

(Scarlet Fever, Scarlet Rash, Canker Rash. 
Ger., Scharlach; Ft., Scarlatine.) 

The period of incubation of scarlet fever varies between twenty-four 
hours and six days, the average duration being about three days. The 
reason of this variation is to be sought, not in any changeability in the 
mode of evolution of the disease, but in the fact that its poison is less 
volatile and less rapidly dissipated than is that of measles, the result 
being that it may remain potential for longer periods in connection with 
articles through the medium of which it is transferred from one indi- 
vidual to another. This incubative period, like that described in con- 
nection with measles, may be unproductive of physical symptoms, or 
may be associated with ill-defined malaise. 

Symptoms — The prodromes of the disease in typical cases are 
marked by the occurrence of a high body-temperature (102°-105° F.), 
a rapid and bounding pulse, an exceedingly dry skin, vomiting, 
headache, and a characteristic sore-throat. When examination of 
the mouth is made, the tongue is seen to be thickly coated, and its 
filiform papillae reddened and prominent, features of the so-called 
"strawberry-tongue." The velum, the pillars of the fauces, the ton- 
sils, and all exposed mucous surfaces are engorged, tumid, reddened, 
and often covered with deep reddish puncta, which represent hyper- 
emia of the perifollicular tissues. Thirst is extreme, and degluti- 
tion is often in the highest degree painful. In severe cases the mucous 
surfaces named may speedily exhibit finger-nail- to pigeon-egg-sized 
ashy ulcerations with a lurid halo at the periphery. In children there 
may be syncope, delirium, convulsions, vomiting, or, when the poison 
has been intense, fatal results from shock of the nervous centres. This 
prodromal period usually lasts from twelve to twenty-four hours, 
though it may be prolonged for two days more. In this respect scar- 
latina is markedly distinguished from measles. This stage is termi- 
nated by the appearance of the exanthem, but the fever persists without 
abatement after the explosion ; and the other symptoms of the disease 
are then in no wise ameliorated. Authors describe three distinct types 
of the disease : the simple, the septic, and the toxic. 

The eruption in scarlatina usually spares the face, however much 
the latter may display two damask-colored cheeks under the febrile 
flush, may become tumid with the blood pumped through the throbbing 
carotids, or even may exhibit a few scanty lesions upon the forehead 
and temples. About the mouth the integument is generally pallid ; this 
is far different from the picture presented in measles. The eruption 
thence spreads rapidly downward over the neck, the trunk, and the 
extremities in symmetrical development, being often conspicuously 
prominent over the elbows, the backs of the hands and feet, and the 
belly. The rash is exhibited, first, in the form of light- or deep- red 
pin-head-sized puncta about the hair-follicles, closely agglomerated; 
and, second, in the form of a superadded erythema, giving to the eye 
the impression of a diffuse reddish blush. The rash develops early 



172 INFLAMMATIONS. 

about the neck and the clavicular regions, and it rapidly spreads to the 
trunk and extremities, including the dorsal surfaces of the hands and 
feet, attaining complete development in the course of the second day. 
It is then of a distinctly scarlet color, whence the disease derives its 
name in Latin, English, and German, a coloration frequently compared 
with the appearance of a boiled lobster. Upon the limbs it often is 
developed in punctate form, while the occurrence of a diffuse scarlet 
blush is perceived most distinctly by the eye in the examination of the 
trunk, where the rash is seen to fade under pressure. In any event 
the erythematous blush commonly disappears before the individual 
elements of the rash are removed. The eruption can be made to dis- 
appear on pressure in the early stages of the affection. Drawing the 
finger-nail rapidly over the surface of the skin is followed by the for- 
mation of a whitish-yellow line, which persists for a time sufficient to 
enable one to describe a letter upon the skin. This period of efflor- 
escence lasts for from one or two days to an entire week, during which 
the febrile and other symptoms continue unabated. 

The rash usually persists at its maximum of development from one 
to three days, the concomitant symptoms continuing without noticeable 
abatement. Among the latter may be named the occurrence of albu- 
min in a urinary secretion of diminished specific gravity, with occa- 
sionally the presence of epithelium, recognizable under the microscope 
as derived from the lining membrane of the uriniferous tubules of the 
kidney. 

Having attained its apogee, the eruption in favorable cases begins 
to fade, the part first affected exhibiting earliest a lighter shade, while 
the other pathological phenomena diminish in severity, the sore-throat, 
especially in ulcerated conditions, alone persisting. In from four to 
ten days longer the eruption disappears, leaving a brownish-yellow pig- 
mentation of the skin-surface ; simultaneously the other symptoms of 
the disease vanish. 

The desquamation which ensues as convalescence progresses is 
general, and is often proportioned in extent to the severity of the pre- 
ceding eruption, though it may be generalized after a well-nigh imper- 
ceptible exanthem. Desquamation is more pronounced and character- 
istic in scarlatina than in any other of the eruptive fevers. It may be 
superficial and furfuraceous in character, or the epidermis may fall in 
lamellated layers ; for example, the sheath of an entire finger, with the 
nail, or that of the entire palm. In this way sheets, ribbons, and 
shreds of the horny layer of the skin may fall from its surface and 
expose a new and often tender epidermis beneath. The hairs may 
simultaneously be shed. When this desquamation is finished the 
stadium of the disease may be regarded as concluded, the entire period 
lasting in uncomplicated cases from a fortnight to a month or six 
weeks. 

The Complications, Anomalies, and remote Sequels of scarlatina 
are so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need merely be reminded in these pages that 
the usual incubative and prodromic stages of the disease may be brief 
as to time, or be followed so brusquely by eruptive phenomena as to be 



SCARLATINA. 173 

indistinguishable. The latter may also first occur upon the extremities 
or trunk, and later on the neck and over the clavicles ; or at once 
cover the totality of the surface by a rapid explosion, or be extremely 
short-lived, or be altogether absent, or be unusually prolonged and 
visible for even a fortnight upon the surface of the body, appearing and 
well-nigh disappearing without appreciable cause. To a proportionate 
extent the stage of desquamation may be reached precociously or tardily, 
and the exfoliating process tediously be prolonged and of intense type, 
jeoparding in this manner the future of the convalescent prostrated 
by the fever which has passed or the sympathetic fever which may thus 
be awakened. 

The anomalies of the scarlatinal rash are numerous, but they depend, 
in general, less upon a variation in the intensity of the poison than 
upon the physical condition of the patient. Thus, the affected surface 
may be elevated slightly above the general level ; there may be no 
coincident pyrexia ; the skin may exhibit irregularly disposed mottlings 
and maculations, the rash may be characterized by the occurrence of 
miliary papules, minute vesicles, blebs, or purpuric lesions, well defined 
against the general scarlet color of the skin by their violaceous shade 
and due to cutaneous extravasation of blood. The rare bullous, pus- 
tular, and urticarial lesions which may appear upon the skin are acci- 
dental and bear no relation to the specific history of the disease. 

Catarrhal and parenchymatous nephritis is justly dreaded during 
the desquamative period of the malady, when it may prove fatal after 
a relatively benignant manifestation of the disease in its prodromal 
and eruptive stages. Gastro-intestinal disorders may also prove 
dangerous. An otitis externa, media, or interna may perforate the 
tympanum, destroy the ossicles, induce caries of the mastoid process 
of the temporal bone, and prove fatal by the eventual production of 
meningitis or phlebitis. To this grave list of disorders which may 
complicate scarlet fever must be added pneumonia, pericarditis, pleu- 
ritis, peritonitis, chronic purulent nasal catarrh (which may result 
in caries of the nasal bones), destruction of the cornea as a result of 
severe keratitis, persistent adenopathy of the subcutaneous glands, and 
malnutrition in many forms, which may so impair the vigor of the 
constitution as to leave the sufferer a physical wreck for the remainder 
of life. 

Septic (Anginose) Scarlatina is characterized by the gravity 
of the throat-symptoms. In such cases a parenchymatous inflamma- 
tion of the tonsils, velum, and fauces supervenes at an early period, 
with enormous tumefaction ; involvement of the submucous tissue and 
neighboring glands ; and ulcerative, suppurative, and even gangrenous 
complications which speedily may prove fatal. 

Toxic Scarlatina (Scarlatiniform Typhus; Fr., Scarla- 
tine foudroyante). — This severe type of the disease is that in 
which symptoms of typhus are pronounced. Here the patient may 
perish within a few hours after attack and before the eruption appears, 
exhibiting comatose or convulsive symptoms, indicating the profound 
influence upon the nervous centres of the intensely intoxicated blood ; 
or the eruption may appear ill developed, often livid, hemorrhagic or 



174 INFLAMMATIONS. 

petechial in type, and be followed by albuminuria, meningitis, diar- 
rhoea, coma, and death. 

Etiology. — The disease is produced exclusively by contagion derived 
from the animal body affected with scarlatina, either mediately or 
immediately, and may occur as an epidemic. It attacks individuals of 
both sexes and all ages, children and infants more frequently, the aged 
more rarely, probably in consequence of their respective conditions as 
regards immunity conferred by a previous attack, since, in general, the 
disease occurs but once in a lifetime. Individual idiosyncrasy must 
account for the cases in which unprotected infants exposed to the dis- 
ease fail to receive it, a fact noted occasionally in epidemics of all the 
exanthemata. The contagious element, which is volatile in its nature, 
seems to be most active during the eruptive stage of the disease. 

Pathology. — Klein has recognized a streptococcus, isolated and 
occurring in chains, which has produced in the lower animals symptoms 
strongly suggestive of scarlatina, but irrefragable proof of the etiologi- 
cal importance of the germ lias not been adduced. Class l describes 
Diplococcus scarlatinse, obtained from scales removed from the skin 
and secretions from the throat of patients affected with scarlet fever. 
The diplococcus is biscuit-shaped and polymorphous, occurring in 
tetrads. Baginsky and Sommerfeld 2 have further recognized bacteria 
as of constant occurrence in cases examined by them. Weaver, 3 how- 
ever, finds that streptococci, though generally are not invariably present, 
and in the latter event outlive all other forms not differing from 
streptococci obtained from other sources. Class obtained an anti- 
toxin proving capable of protecting guinea-pigs against the disease 
inoculated in animals which died in control-experiments in six or seven 
days. Baginsky and Summerfeld 4 seem to have in a measure verified 
the observations of Class : but more recently Mallory 5 has recognized 
bodies supposed to be matozse in victims of scarlatina. The essential 
micro-organism of scarlet fever, however, has not been demonstrated. 
Scarlatina at times follows injuries and surgical operations, due, as 
Atkinson 6 supposes, to diminished powers of resistance to the disease. 

The cutaneous lesions of scarlatina, like those of measles, depend 
upon hyperemia due to vascular dilatation of blood- and lymph- 
vessels, and a moderate degree of exudation. The latter, when it 
occurs, is limited for the most part to the rete and papillary layer of 
the corium. There is no diapedesis of leucocytes, though clusters of 
connective-tissue cells may be demonstrated about the papillary loops 
of the capillaries. Mast-cells and mitoses appear when desquamation 
begins ; plasma-cells are absent. According to von Jurgensen, the 
result is a vasomotor paralysis of the peripheral vessels. The signs 

1 Med. Record, 1899, lvi., p. 330 and p. 513 ; Jour. Amer. Med. Assoc., 1900, 
xxxv., p. 799. 

2 Berlin, klin. Wchnschrft., 1900, xxxvii., p. 588 and p. 618 ; Lancet, 1900, ii., 
p. 1234. 

3 Jour. Med. Resell., 1903, ix., p. 246. 

4 Berlin klin. Wchnschrift, 1900, No. 22. 

5 Jour. Amer. Med. Assoc, 1904, xlii., p. 37. 

6 Jour. Cutan. Dis., 1886, iv., p. 295. 



SCARLATINA. 175 

of the disorder are not apparent in the dead body unless there have 
been exudation of blood and the consequent formation of petechia. 

According to Unna, the epidermis, when the disease is fully devel- 
oped, is the seat of a parakeratosis productive of scaling, while the 
prickle-layer shows neither oedema nor emigration. In the cutis there 
is a maximum of congestion without distinct oedema. The general 
vasomotor disturbance leading to a species of vascular paralysis is 
supposed to be due to changes in the nervous centres produced by the 
disease. 

The Diagnosis of scarlatina from measles, rotheln, erysipelas, and the 
erythemata in general is established readily. The sore-throat, intense 
fever, punctiform scarlet rash reaching to the border of the inferior max- 
illa, and the distinct, whitish-yellow line traceable by the finger-nail when 
passed rapidly over the surface, are all characteristic. In measles the 
macular character of the rash and its crescentic arrangement, in con- 
nection with the catarrhal symptoms, will usually be recognized. From 
erysipelas scarlatina can always be distinguished by the absence of the 
peculiar, shining, smooth, or glazed and tumid condition of the affected 
area. From all other rashes scarlet fever can be distinguished by the 
pyrexic symptoms and resulting desquamation. For the distinction 
between scarlatina and erythema scarlatiniforme the paragraphs 
devoted to a description of the malady last named may be consulted. 

Great care should be taken not to confound the drug-rashes having 
a scarlatiniform appearance with the specific disease under considera- 
tion. Thus, belladonna, in doses of 1 minim of the tincture every 
hour to the extent of four doses, has produced an abundant scarlatini- 
form eruption in children, a diagnostic point of importance in view of 
the fact that the drug named has been employed as a prophylactic 
against the disease. For eruptions of this sort due to quinine and 
other drugs the reader is referred to the pages devoted to Dermatitis 
Medicamentosa. 

Treatment. — The modern treatment of uncomplicated scarlatina is 
antiseptic and expectant, after provision is made for an abundant supply 
of fresh air, disinfection, a proper regulation of food and drink, and 
the local use of baths, tepid or cool, for the purpose of reducing the 
body temperature. After these baths the skin should be anointed 
freely with a fatty substance, such as cold-cream salve, scented 
almond- or olive-oil, or with vaselin. These inunctions are not only 
grateful to the patient, but they also reduce the body-temperature to a 
slight degree. All treatment other than that suggested above per- 
tains to the field of general medicine, and should be limited to the 
special conditions presented in each case. Such treatment includes the 
management of disorders of the eye, ear, throat, kidneys, and other 
viscera, the involvement of which constitutes a complication of the 
disease. 

The Prognosis of the malady should always be established with 
reserve. It is largely based upon the relative intensity of the symp- 
toms, the vigor and age of the subject, and the presence or the absence 
of serious complications. Albuminuria is rarely absent, and is not per ae 
alarming ; but anasarca and other evidences of profound interference 



176 INFLAMMATIONS. 

with the renal function are to be assigned due weight. In general, 
it may be said that a high range of temperature ; early and ulcerative 
throat-lesions ; the puerperal state ; tardy development, rapid and un- 
timely disappearance, or undue prolongation of the exanthem ; and its 
admixture with petechise to such an extent as to indicate extensive 
hemorrhagic extravasation, are all formidable symptoms. Finally, it 
must not be forgotten that the mildest and simplest forms of the disease, 
after the fastigium is passed and convalescence is actually established, 
may terminate fatally by the supervention of ursemia, cerebral paralysis, 
or even meningitis, consequent upon secondary changes in the middle 
or internal ear. 

VARIOLA. 

(Lat. varus, a blotch. ) 

(Small-pox, The Pocks. Ger., Blattern, Pocken ; Fr., Petite 
Verole; Ital. y Yajuolo.) 

The variations of variola as to the severity, character, and duration 
of its symptoms are so great as to preclude complete description of this 
malady within the limits here assigned. The following paragraphs are 
therefore devoted to a sketch merely of its more commonly recognized 
characters. 

Symptoms. — The period of incubation of the unmitigated disease 
varies between five and twenty or more days, occupying usually twelve 
days or a fortnight. It is characterized by the peculiarities of that 
period recognized in all the exanthemata, there being few and insignifi- 
cant or no evidences of physical discomfort. The prodromic stage is 
ushered in generally by a vespertine chill, succeeded by fever, with a 
temperature rising to 104°-106° F., which is commonly associated 
with severe and characteristic pain in the loins, headache, epigastric 
pain, nausea or vomiting, and occasionally in young subjects with 
delirium and convulsions. The fever continues, with alternations of 
exacerbations and partial relief, or sensations of chilliness, during the 
second and third days. At the same time there may be faucial hyper- 
emia and moderate dysphagia. Occasionally, before the cutaneous 
exanthem appears, minute reddish papules may be recognized upon the 
buccal membrane. 

Initial Bashes (Variolous Erythema ; Variolous Kose- 
ola). — These may be either (a) erythematous in character, and gen- 
eral or partial ; or (6) hemorrhagic, in the form of pure petechise or of 
admixtures of petechial and erythematous blotches. 

On the second and third days there appears, in some cases, espe- 
cially in menstruating women and in young subjects, a cutaneous 
efflorescence, the significance of which may be misinterpreted, thus 
leading to errors in diagnosis. To Hebra we are indebted for its dis- 
tinct recognition as a cutaneous prodrome in variola. The interpretation 
of this exanthem is a matter of special importance to the diagnostician, 
as many have been deceived respecting its nature and significance. It 

1 Cf. Discussion on small-pox before Amer. Derm. Assoc., May, 1901, Jour. Cutan. 
Dis., 1901, xix., p. 484. 



VARIOLA. 177 

is characterized by the occurrence of irregularly disposed and distinctly 
outlined maculations, puncta, striae, streaks, or a diffuse blush of bright 
or lurid reddish hue ; the invaded integument being at times slightly 
tumid, and thus elevated above the general level. The affected part 
may also be the seat of moderate pruritus. The blush may fade under 
pressure, but rarely does so perfectly. One cannot by the finger pro- 
duce upon it a visible whitish spot. The rash may be diffused widely, 
but occurs most often about the groins, the hypogastric region, the pubes, 
and the inner faces of the thighs; and on examining these parts the 
physician will usually discover the evidence, in adult women, of recent 
or present menstruation, or of the puerperal state. It occurs also 
about the axillae, the extensor faces of the larger and smaller joints, 
and the lumbar and clavicular regions. Often a broad area of the 
integument in these parts may exhibit a sheet or mask of dull crimson 
erythema, upon which may form pinhead- to bean-sized, dull-reddish 
papules, not losing their color under pressure, or more rarely petechiae, 
vesicles, and wheals. All these are precursory phenomena, and are 
not transformed into characteristic variolous lesions. They fade almost 
completely before the latter appear. Rarely, a few scattered papules 
may be distinguished upon the face and the arms before the variolous 
erythema fades. Often the papules in full development are even less 
profusely displayed on the site of the precedent efflorescence. The 
latter need not be necessarily regarded as a symptom of portentous 
gravity. The entire surface of the belly may be covered with a uni- 
form erythematous blush of dull-crimson hue, followed by confluent 
variola, and the patient ultimately recover. The physician, then, con- 
fronted with a deep-red erythema of the regions named, especially of 
the groins, the lower part of the belly, and the thighs of a menstru- 
ating woman affected with high fever, nausea, vomiting, and lumbar 
pain, should invariably suspect the presence of variola. 

The vividly red or empurpled rashes of hemorrhagic type occur 
most frequently in the localities named above when the disease assumes 
a grave aspect, as in hemorrhagic variola. 

The Small-pox Eruption. — The period of the eruption in variola 
is characterized, at its earliest, by punctiform, subcutaneous discolora- 
tions which photography alone can reveal. Commonly the patient 
will be seen on the morning of the third or oftener the fourth day 
with the face and scalp covered with pin-head-sized and larger, firm 
conical papules, the touch of which to the finger suggests to most 
English observers the feeling of shot embedded within the skin. 
Later, these papules develop upon the trunk and limbs ; and in well- 
marked cases every portion of the body-surface is invaded, including 
the palms and soles. The lesions may be surrounded by a narrow 
rosy areola upon the trunk. They may be unproductive of subjective 
sensations or be slightly tender. 

As a rule, there is complete defervescence when the exanthem ap- 
pears, the patient experiencing such relief that if an adult has chanced 
not to view his face in a mirror nor to be informed of his appearance 
by those in attendance upon him, he often will regard himself as com- 
12 



178 



INFLAMMA TIONS. 



pletely relieved of his three days' illness. In other cases the febrile 
symptoms persist with a lowered temperature. 



Fig. 36. 




Vertical section of pustule at the beginning of pustulation : a, umbilication at the site of an 
excretory canal ; b, reticulum within the epidermis ; c, reticulum of smaller meshes containing 
lymph- and pus-globules. (After Rindfleisch.) 



During the first two days of the eruptive period the papules increase 
in number and become correspondingly agglomerated ; while those of 
earliest appearance become transformed into vesicles containing a trans- 
lucent serum, the roof-wall of many of them exhibiting an umbilica- 
tion. This umbilication of the vesicle, though not invariably present, 
is characteristic, and slightly different from that observed in bullous 
and pustular lesions. The central depression is disproportionately 
large, and about it the yet undistended epidermis is often irregularly 
puckered or fluted. Even in this period the lapse of a few hours will 
produce a lactescent appearance in the formerly translucent contents. 
The mucous surfaces adjacent to the skin may similarly be involved. 

From the sixth to the twelfth day the transformation of these lesions 
into pustules is effected, the process beginning, as in all the metamor- 
phoses of the disease, in the vesicles of greatest age, those, namely, on 
the face and upper portions of the body. The lesions simultaneously 
enlarge until they are of the size of an average-sized pea, are surrounded 
with a distinctly ovoid areola, and, being fully distended, rupture the 
centrally placed filament which held down the roof-wall, consequently 
the umbilication of the pustules is lost. The integument upon which 
they develop becomes visibly tumid. With this process of suppura- 
tion is awakened the so-called " secondary fever," a pathological process 
evidently not essential to the disease, as it does not occur in mitigated 
cases. This secondary fever is born of the extensive process of suppura- 
tion occurring in the skin and other organs, and may be symptomatic, 
sympathetic, or septicemic in character. It thus varies in different 
cases with the character and severity of the process by which it is 
excited, being transitory in mild cases, and in others terminating only 



VARIOLA. 179 

with death. At this time the patient is usually in a most distressing 
condition. The skin of the face and of other attacked regions is 
swollen, thickly covered with pustules, and the features indistinguish- 
able in the tumid and closed lids, the cedematous lips, disfigured nostrils, 
and pus-obstructed mucous outlets. Deglutition becomes painful and 
often impossible, the saliva flows from the lips, and the mucus from the 
nares dries with the pus upon the exterior of the visage. The pustules 
recognized upon the integument are represented also in the gastro- 
intestinal tract. In an autopsy of a patient dead at this stage of the 
disease the entire canal from the mouth to the anus, as also the genito- 
urinary and respiratory passages, may be completely covered with 
closely agglomerated and well-distended pustules. The career of those 
within the mouth can usually be studied by eye-observation. In this 
situation they rapidly lose their epithelial roof-w T all by reason of the 
heat, moisture, and friction to which they are subjected, and then 
exhibit a reddened and excoriated surface, over which there is re- 
formation of the epidermal layer. Gangrenous complications are rare. 
In this condition women who are pregnant frequently abort or mis- 
carry, the foetus coming into the world exhibiting cutaneous symptoms 
of the disease. 

Between the thirteenth and the fourteenth day desiccation begins, 
and is usually completed within from ten days to a fortnight ; the pus- 
tules rupture, and the exuded pus concretes into yellowish or brownish, 
rarely blackish crusts, or the latter are formed by the desiccation of 
the entire envelope and contents. The pulse usually at the same 
time diminishes in frequency and secondary defervescence occurs, the 
tumefaction of the integument decreases, and at times the peculiarly 
characteristic and often intolerably fetid odor from the patient is less 
perceptibly exhaled. In from four to six weeks the course of the 
disease is completed. The immediate traces of the eruption are purplish 
and violaceous pigmentations, which slowly disappear. When cicatrices 
result they are slightly depressed, at first of a dull purplish hue, later 
dead-white, lustrous, usually symmetrical in disposition, and most 
distinct upon the surfaces exposed to the light and air, such as the face. 
Though persistent, they are rendered somewhat less deforming in the 
progress of years. When closely set together they produce a character- 
istic ridged and corded appearance, due to the elevation of narrow 
bands of unaffected integument between the depressed surfaces of scars. 
The several departures from the pronounced type of the disease described 
above present variations differing widely from the most benignant forms. 
Brief reference only can be made to these variations. 

Varioloid, whether occurring after vaccination or not/ is a 
modified type of variola. With it should be classed all these forms 
of the disorder occurring in the human subject, and described by 
authors under the titles " wart-pox," " horn-pox," variola siliquosa, 
miliaris, verrucosa, crystallina, cornea, etc. In these cases there may 
be a severe prodromic fever and a scantily developed exanthem ; rapid 
involution of lesions ; abortion of the latter in any of their several 
stages from papule to crust • absence of secondary fever ; transmission 



180 



INFLAMMA TIONS. 



of the disease in a mild or mitigated form from one individual to 
another, so that an entire community, vaccinated and unvaccinated 
alike, may suffer from an epidemic disorder of this moderate grade 



Fig. 37. 







m : mm^^~ 



Vertical section of one-half of an undeveloped variola-pustule : or, old epidermis ; o.epithelia 
of rete above the alveoli; c, new-formed epidermis ; d, alveoli filled with pus-globules; g, flat- 
tened and infiltrated papillae lying beneath the pustule. (After Auspitz and Basch.) 

without the occurrence among them of a single case of typical variola. 
It is scarcely necessary to add that a patient with varioloid, especially 
during an epidemic, may transmit to the unprotected a malignant form 
of the disease. 1 

Hemorrhagic Variola (Black Small-pox, Variola Nigra 
Maligna), fortunately rare and confounded in the past with " black 
measles," is formidable viewed from every point. 

The disease is developed in two fairly distinct types : the one pur- 
puric, most often seen in subjects debilitated by alcoholism, enfeebling 
maladies, in infants, and in women in the puerperal state ; the other, 
with pustular lesions. 

When cutaneous hemorrhages occur during the course of small- 
pox they do not necessarily indicate that the case is one of so-called 
varioliform purpura, since these losses may be accidents of the 
pathological process. In this malignant form of the disease, against 
the ravages of which vaccination often presents but a feeble barrier, 
the prodromic stage is followed by a deep purplish redness of the 
surface which is characterized by pin-head- to split-pea-sized, firm, 
closely set papular lesions, suggesting the occurrence of measles in a 
peculiarly severe form. The febrile, nervous, and other symptoms of 
the disease are proportionately intense. Ecchymoses appear upon the 



1 For a consideration of the symptoms and diagnosis of modified small-pox as it 
has appeared in recent epidemics, see Welch, Phila. Med. Jour., 1899, iv., p. 973, and 
paper by one of us (Hyde) published by Illinois State Board of Health, 1900. 



VARIOLA. 181 

conjunctival membrane. Gradually the color of the exanthem, that at 
first disappeared under pressure, refuses thus to yield and assumes a 
bluish-black shade. Ecchymotic patches may be intermingled with 
the papules, rapidly widening to palm-sized and larger areas. The 
mucous surfaces share in these colors, being also infiltrated with effused 
blood, and the muco-cutaneous orifices are crust-covered and exhale 
an extreme fetor. Blood may escape from the bowels, bladder, mouth, 
or vagina. Signs of grave systemic and visceral complications are 
always present. Vesiculation, pustulation, and the typical transforma- 
tions of variolous lesions may be present, the blood in most cases 
becoming extravasated at the base or border of the lesions interspersed 
with petechia?. In the few cases observed by us death speedily super- 
vened, either from shock, coma, hemorrhagic infarction of the lungs, 
or rapid exhaustion. Intermediate forms between hemorrhagic and 
true variola are described, in which forms the pustules occurring in 
the variolous type of the disease merely fill with blood in consequence 
of accidents possessing a purely local significance. 

Confluent Variola is another severe form, less malignant, how- 
ever, than that just described. It is characterized by intensity of the 
prodromic fever, which often scarcely abates with the appearance of 
the exanthem. The latter is developed in deeply implanted, firm pap- 
ules, closely set together, succeeded by vesicles and pustules, which, 
as they enlarge, fully occupy the entire surface of the integument, and 
accomplish a perfect coalescence. In well-marked cases there is scarcely 
a pinhead-sized area of the entire surface of the body that is not 
invaded. The tissues become enormously oedematous; the deformity 
of the face renders the features indistinguishable. Hemorrhagic pus- 
tules and even patches of a gangrenous pulp may be intermingled with 
sheets of suppurating surface. Phonation, respiration, and degluti- 
tion are impeded proportionately or are subverted absolutely by the 
tumefaction and suppuration of the mucous membranes of the respira- 
tory and gastro-intestinal tracts. When the patient survives until the 
stage of desiccation is reached, the body presents a revolting aspect. 
A thick brownish or blackish-brown mask envelops the swollen head, 
trunk, and limbs, and the odor exhaled from the body is intolerably 
repulsive. All the systemic phenomena are proportionately grave, and 
are accompanied by one or more of the complications of the malady — 
pneumonia, pleuro-pneumonia, albuminuria, diarrhoea, various motor 
and sensory paralyses, subcutaneous furuncles, and abscesses. The 
eyes may suffer from pustular and ulcerative changes in the conjunctiva, 
cornea, and deeper tissues, with resulting inflammation of every grade 
to panophthalmia and consequent loss of vision. Often the patients, 
with surprising powers of resistance, will survive until extensive sheets 
of crusts have fallen from the skin-surface, and then perish slowly in a 
typhoid condition with low remittent or continuous fever. Every such 
case does not, how 7 ever, terminate fatally. Both adults and children 
may rally from the severest form of confluent variola, and afterward 
enjoy vigorous health. 



182 INFLAMMATIONS. 

Etiology. — Variola is always the result of mediate or immediate 
contagion. It is a disease both contagious and infectious, being often 
epidemic and transmissible by volatile emanations from the victims of 
the disease. It is also artificially inoculable. When transmitted by 
the latter process its period of incubation is somewhat shortened, and 
often its successive manifestations become less formidable. The history 
of inoculated human variola has received, however, but little attention 
during late years, since the practice properly has been forbidden by law. 
The disease is, to a certain extent, transmissible from man to the lower 
animals, and the reverse. It attacks individuals of both sexes and all 
ages, including the foetus in utero, which may be ushered at an untimely 
hour into the world, macerated or recently dead and covered with the 
lesions of variola. The disease in the larger cities is decidedly more 
frequent in winter than in summer, possibly because in the colder 
months the opportunities are greater for spread of the contagion in 
artificially heated dwellings in which numbers of individuals are 
crowded together. Islanders, long unvisited by an epidemic and un- 
protected by vaccination, may suffer equally in the summer season. 

Pathology. — The latest investigations on the pathology of variola 
have been made by Councilman, Magrath, and Brinckerhoff. 1 These 
observers believe that the peculiar inclusions within the epithelial cells, 
previously described by Guarnieri in 1892, and after him by others, 
sustain relations to the etiology of the disease. 

In the lower layers of the epithelia structureless bodies are seen 
from 1 to 4 // in diameter, lying in intercellular vacuoles which at first 
are scarcely larger than the contained bodies. The vacuole, however, 
increases in size as these bodies become larger, more definitely granular, 
and more distinctly located. Segmentation of the mass occurs later 
with the formation of round bodies about 1 p. in diameter. These 
intercellular bodies are regarded as living organisms. 

When segmentation is completed, small, round, oval, or ring-like 
bodies appear in the nucleus which increase in size, acquire a definite 
structure, and consist of a series of vacuoles around a large central 
vacuole, one or more appearing at times within a single nucleus. 

The intranuclear body is believed to be an advanced stage of the 
development of the intracellular body, springing from the spore-like 
elements produced by segmentation of the intracellular body, which 
pass into the nucleus. The spores formed by its segmentation are 
probably the " true infecting material of variola." Inoculation of 
rabbits with the contents of variola-pustules has given origin to lesions 
in which both the intracellular and the intranuclear organisms have 
been recognized. It is believed by these observers that in small-pox 
the parasite passes through two cycles, but that in vaccinia the primary 
cycle alone is traversed. The spore-like body formed in this cycle, 
when introduced into an unprotected human subject, produces vaccinia. 

Coze, Feltz, Baudouin, Luginbiihl, Weigert, Hallier, and Colin 

1 Jour. Med. Eesch., May, 1903, ix., p. 372. See also Funk, Brit. Med. Jour., 
1901, i., p. 448 (abstr. in Archiv, 1903, lxv., p. 290) ; Stokes, Bull. Johns Hopkins Hosp., 
1903, xiv., p. 214 ; Sanfelice and Malats, Archiv, 1902, lxii., p. 189 ; Thompson, Jour. 
Med. Resch., 1903, x., p. 71. 



VARIOLA. 183 

recognized both bacteria and micrococci, in the blood of variolous 
patients. Cohn l regards these parasites as instances of a " twin race " 
of Micrococcus vaccinas discovered in vaccine-lymph. The second- 
ary fever of the disease is without question septicemic, and is due to 
pus-cocci and their toxin. 

According to Unna, the main distinction between the vesicle of vari- 
cella and that of variola lies in the slow growth of the one and the prompt 
suppuration which is added to the fibrinoid degeneration of the other. 
The epithelium of the lower prickle-layer undergoes speedily " balloon- 
ing colliquation " not only at the apices of the papillae, but also in the 
depths of the ridges. A gradual division of the vesicle follows into an 
upper and a lower story, with a lateral extension of the cavity in the 
upper prickle-layer, a somewhat characteristic oedema, and mitotic pro- 
liferation of the semisolid cushion below. The umbilication is pro- 
duced less by the action of centrally placed epithelia acting as guy- 
ropes than by the enormous force of the exudation at the periphery in 
contrast with the slight activity of the central parts, as a result of which 
the latter are simply " left behind.'' Gradually there follows a dense 
collection of plasma-cells in the adventitial sheaths of the blood-vessels. 
The latter subsequently dilate, and the line of demarcation between 
the cutis and rete becomes well-nigh indistinguishable on account of 
the stream of leucocytes thither. Healing begins at a later stage by 
the formation and gradual contraction of a thin layer of epithelial cells 
lying close to the connective tissue and extending from all sides beneath 
the pustule. 

Diagnosis. — The difficulty attending the diagnosis of variola in its 
prodromic and earliest eruptive stages, from measles, is considered in 
the description of the latter disease. The general demand, indeed, 
upon the physician for an exact and definite diagnosis of every case 
before its complete evolution, is founded upon an erroneous conception 
of possibilities, and the sooner this generally is recognized the better. 
A delay of even a few hours will often verify or remove a suspicion. 
Fully as much mortification on the part of the physician and damage 
to the best interests of the patient may result from an error in one 
direction as in the other. The wisest course in every doubtful case is 
to admit the doubt and to visit the patient frequently for the purpose 
of observing the development of the disease until that doubt is removed. 
Typical cases of variola are recognized with ease from the character of 
the symptoms presented. Measles and scarlatina resemble variola only 
during the period in the last-named disease when the variolous rashes 
are present. The symptoms of diagnostic importance at this period 
are, the presence or absence of fever, of catarrhal symptoms, of lumbar 
pain, the site of first appearance of lesions, and the duration of the dis- 
ease. Impetigo, and, in particular, impetigo contagiosa, is a non-febrile, 
almost never generalized, affection of the face and hands — in point of 
fact a finger-nail-filth disease. Its particular lesions are relatively few, 
and not umbilicated. Varicella (chicken-pox) is characterized by the 
occurrence of the thin- walled, translucent, superficially situated vesicles 
first developing on the trunk, later on the face, with a mild fever accom- 

1 See Magnan, loc. cit., p. 411. 



184 INFLAMMATIONS. 

panying instead of preceding the rash. They are never indurated 
nor umbilicated. Accidental and secondary eruptions which may be 
present are recognized by the history and features of each. 1 Syphilis 
and acne are always distinguished by the absence of fever and their 
relative chronicity. 

The Prognosis of variola is largely dependent upon the degree of 
protection conferred by previous vaccination. Independent of vacci- 
nation, the age and vigor of the patient, the presence or absence of an 
epidemic of severe or mild type, the extent of the eruption, and the 
character of the surroundings of the patient are elements of prime 
importance. Very young and aged subjects, women pregnant or in 
the puerperal state, and, as Hebra has shown, those who have suffered 
from a previous attack of the same disorder, are all unfavorably dis- 
posed with respect to the final result. Confluent and hemorrhagic forms 
of the disease are, naturally, the gravest. Unmitigated variola, under 
the most favorable circumstances, is one of the greatest scourges of iiu- 
manity, and as such will probably always destroy a frightful propor- 
tion of its victims. At the same time the conscientious physician 
needs to be impressed with the fact that, under the most discouraging 
circumstances, the patient, disfigured to the greatest extent by an en- 
velope of blackened crust, and in a state of extreme physical prostra- 
tion, with many of his bodily functions almost completely suspended, 
may even from the midst of such peril be won back to life and vigor. 
The assiduous attentions of a skilful nurse, guided by the inspiring 
presence and councils of a physician who is himself fearless of the 
malady, will often achieve the result. Upon the latter point it is 
interesting to note that physicians in active practice who do not hesitate 
to expose themselves freely to the disease in the discharge of the duties 
of their profession rarely suffer in their own persons. 

The Treatment of variola should, in general, be limited to the 
indications presented in each case. No remedies can be employed 
which have the least power to abort the disease. Kaposi calls atten- 
tion to the striking fact in this connection, that syphilis, for many of 
the manifestations of which mercury is a specific, is a disease the second 
incubation-period of which is measured by weeks, and yet neither by 
excision of its initial sclerosis nor by mercurials can the subsequent 
manifestations of the disease be completely prevented. Certainly no 
specifics are recognized as of value in variola. The patient should be 
kept in a relatively dark room with an abundant supply of fresh air 
of a uniform temperature, and antiseptic solutions should constantly 
be at hand into which all the ejecta are received immediately. He 
should be given ice when this is acceptable to the palate, cool water 
ad, libitum, and his strength should sedulously be supported by a liquid 
animal diet. The body may be sponged with or bathed in cool or 
tepid water as often as is grateful to the patient. In severe or con- 
fluent cases the immersion of the body in the continuous warm water- 
bath is followed by brilliant results in hastening the desiccation and 
fall of the crusts and subsequent repair. A bath of this character given 
for merely two or three hours in the day is often of great value. With 
1 Schamberg, Jour. Cutan. Dis., 1903, xxi., p. 215. 



VARIOLA. 185 

and without these external measures gargles of potassium chlorate, 
myrrh, honey, or carbolic acid will be found acceptable to the mouth 
and palate. The constant attention of an efficient nurse bestowing 
assiduous care upon the mouth, the skin, and the eyes may be regarded 
as an essential part of all sound treatment. 

With a view to the prevention of pitting, no measures of a therapeu- 
tic character will prevent the occurrence of a distinct cicatrix whenever 
pus has eroded or otherwise destroyed the integrity of the papillary 
layer of the corium. Every effort, therefore, should be exerted to 
prevent extension of the suppurative process to the true skin. The 
following measures have approved themselves as of practical value : 
First, the sick-room should be moderately darkened and yet be amply 
provided with fresh air. Second, a solution of pure sodium hypo- 
sulphite should be administered night and day in the dose of from 15 
to 20 grains (1.-1.3) every three or four hours. Salol, 1 iron, strych- 
nine, quinine, digitalis, and opium, are indicated at times. The vario- 
lous lesions pursue a milder course under this internal treatment, and 
in some cases even the vesicles shrivel before pustulation is fairly 
begun. Third, the skin of the face, after sponging with a weak 
formalin lotion, should be anointed with a bland fatty substance such 
as vaselin, almond-oil, or fresh lard, and over the unguent may be laid 
silk-enveloped compresses, dipped in tepid, weak solutions of carbolic 
or boric acid, or of thymol. The unguents thus employed are medi- 
cated at times with boric or carbolic acid, zinc oxide, resorcin, bis- 
muth, sulphur, or other ingredients. The anointing of the surface 
before the application of the lotion is commonly more grateful to the 
patient, but the skin may be moistened with the aqueous lotion alone. 
Here, again, the assiduous attention of the nurse is a matter of im- 
portance. The powder of europhen topically often is applied with 
advantage. 

The edges of the eyelids should daily be anointed with freshly 
prepared cold-cream salve. Puncture of the cornea may be required 
for the relief of hypopyon. Diarrhoea and other symptoms of visceral 
derangement should be relieved by appropriate medication. As a rule, 
the administration of narcotics for the relief of pain is objectionable. 
Throughout the course of the disease the strength of the sufferer should 
be supported by a generous use of animal broths or of milk ; in typhoid 
conditions a judicious employment of stimulants may be necessary. 

The red-light treatment of small-pox devised by Fin sen has been 
tried in a considerable number of cases with excellent results. 2 In 
America the method has received little attention. A few observers 
have reported failure with the treatment, but in these instances it is 
not clear that the technique was carried out properly. 

1 Beg#, Scot. Med. and Surg. Jour., 1900, p. 222 (abtsr. in Brit. Jour. Derm., 1900, 
xii., p. 184). 

2 Phototherapy, translated from the German by J. H. Seqneira, London, 1901. 
Brown, Brit. Med. Jour., 1903, ii., p. 1409 ; ISaunyn, L nterelsassischer Arzteverein, 
Sitz. 26 Juni, 1903 (abstr. in Munch, med. Wchnschrft, 1903, l.,p. 1360) ; Depray, Jour, 
med. de Bruxelles, 1903, viii., p. 69 ; Emmerson, Med. Times and Hosp. Gaz"., 1903, 
xxxi., p. 419; Carassa, 11 Morgagni, i., No. 4 (abstr. in Monatshefte, 1903, xxxvi., p. 
336) ; Munch, med. Wchnschrft., 1903, 1., p. 1810. 



186 INFLAMMATIONS. 

The treatment is based on the principle of excluding the chemically 
active rays from the skin of the affected patient. For this purpose 
the subject is placed in a room to which no light is admitted that is not 
first filtered through red glass or other material that will effectively 
shut out all the chemical rays. As a control-test, sensitized photo- 
graphic plates are hung in the room, and if they at any time show the 
influence of white light the technique is not perfect. Finsen states 
that " when the patient comes under treatment early enough, before 
the fourth or fifth day of the disease, suppuration of the vesicles — even 
in unvaccinated persons and in cases of confluent small-pox — will be 
avoided, with one exception out of about seventy. . . . Should the 
patient come under treatment after the fifth day of the disease, it is 
uncertain whether suppuration can be avoided." 1 

This method apparently has prevented suppuration, secondary fever, 
and scarring, in more than 100 cases, and is certainly worthy of a 
thorough trial. 

VARICELLA. 

(Chicken-pox. Ger., Spitzblattern, Wasserpocken ; 
Fr.j Variolette; Ital., Moroiglione.) 

Symptoms. — This disease has an incubative period lasting from ten 
days to a fortnight, after which there is occurrence of malaise, chilli- 
ness, and languor. The patients are usually children, who may suffer 
thus from fever of a moderate grade (99°-100° F.) lasting from a few 
hours to two or three days, after which defervescence is commonly com- 
plete. With the onset of the fever or even without, the rash appears, 
first on the head and trunk, in the form of rosy macules or slightly 
elevated lesions lacking the characteristic " shot-like " feeling of the 
variolous papule. These macules rapidly become vesicular, the lesions 
being pin-head- to pea-sized, rounded or oval, well-projected from the 
surface, limpid, superficial in situation, differently shaped from vario- 
lous lesions, and almost never umbilicated, puckered, or "fluted" as 
in small-pox. The macules appear in successive crops, often first over 
the upper posterior aspect of the trunk, where the typical evolution of 
the disease is best studied, and then the elements of the eruption are 
surrounded often by a faint pinkish or reddish halo. Their contents 
become cloudy or lactescent rather than puriform, and they desiccate 
as early as the second day, forming thin, light, superficial crusts. The 
lesions may be abundant in one region, as, for example, over the back 
or the chest, but are never both abundant and generalized and are 
invariably discrete, never confluent. They rarely occupy the palms 
and soles ; and the vesicular lesions may develop as such, or spring 
from the macules, the latter, however, not invariably going on to vesic- 
ulation. They may occur in crops or simultaneously involve several 
regions of the surface of the body. They may develop after typical 
variola. 2 Like variolous lesions, they extend at times to the mucous 
surfaces of the eyes, the mouth, and the genital regions. Occasionally 

1 Jour. Amer. Med. Assoc, 1903, xli., p. 1208. 

2 Schamberg, Phila. Med. Jour., 1902, ix., p. 442. 



VARICELLA. 187 

they are productive of pruritic sensations. Often the course of the 
disease is so mild and the exanthem so slight as scarcely to attract 
attention. Cicatrices result only in places, chiefly the face, where the 
lesions have been subjected to local irritation. 

Etiology. — The disease is infectious, and if inoculable such a result 
rarely is obtained. In the large majority of all cases it is a disease of 
infants and children ; and though an enormous experience of authors 
is cited to the contrary, we have observed it in a few instances in 
adults, and even still more rarely in advanced years. Second attacks 
may occur, but are infrequent. The source of the disease is invariably 
an infected subject. 

Diagnosis. — The doctrine that varicella is a mitigated form of 
variola has been practically abandoned in consequence of the researches 
of pathologists. It is of vast importance that the essential differences 
between the two diseases be exactly and generally recognized. 

In variola the invasion-period of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of the 
patient, the thermic variations, the prodromic rashes, and the rapid 
transformation of the papules into umbilicated vesicles, are all 
important diagnostic points. In varicella the trunk usually exhibits 
the greater number of lesions, which appear often in successive crops. 
Beside the characteristics of the cutaneous lesions the catarrhal symp- 
toms of measles and the sore-throat of scarlatina will point to the 
nature of these disorders. Impetigo contagiosa is to be carefully dis- 
tinguished from varicella, since the two affections occur at times side 
by side in one hospital ward, and occasionally the former succeeds the 
latter. The lesions of impetigo contagiosa are often larger, generally 
more persistent, and the crusts bulkier than in varicella, and the 
patients rarely exhibit pyrexic symptoms. 

Pathology. — If the observations of Councilman, Magrath, and 
Brinckerhoff be confirmed, the parasite of varicella is that of 
variola (q. v.), which, however, in lieu of completing a double, has 
traversed but a single, cycle of its life-history (cf. Pathology of 
Variola). Clinical experience lends support to these laboratory 
conclusions. According to Unna, the varicellous process begins with 
a " reticulating liquefaction " of some of the prickle-cells of the central 
and upper portion of the rete in which the first congestive focus is 
seen. The complete liquefaction of the contents of the loculus is fol- 
lowed by confluence of adjacent cavities and rapid dilatation to the 
point of formation of a vesicle, the non-liquefied and persistent epithe- 
lium being compressed so as to form the septa, while the cells above 
produce similarly the roof-wall. The epithelial cells of the base undergo, 
on the other hand, "ballooning colliquation " (transformation of cells 
into hollow spheres or balloons having the form of peculiar giant-cells), 
a change affecting especially the centre of the pock, its lateral margins, 
and even at times its septa. Internally, these ballooned cells merge 
into simple cedematous epithelium with constricted nuclei. Careful 
observation of the lesions of varicella demonstrates that the vesicles are 
as distinctly divided into septa as are those of variola. These lesions 



1 88 INFLAMMA TIONS. 

are never monolocular. Their benign course is explained pathologi- 
cally by their superficial position, by the absence of purulent infection, 
and by early repair with young epithelium. The absence of umbilica- 
tion is explained by the acuity of the process. Bareggi, Guttmann, 
Pfeiffer, and others claim to have discovered micrococci and protozoa 
both in the blood-corpuscles and in serum obtained from subjects of 
the disease ; but no pathogenic relation of these germs has been estab- 
lished. 

Treatment. — The management of uncomplicated cases of varicella 
is limited to the avoidance of exposure to sources of aggravation of 
the affection. Often a dusting-powder may be applied over the sur- 
face after a lotion of thin oatmeal-water. Cases complicated by the 
accidents of exposure or by the intensity of the disease are to be 
treated by the resources of general medicine according to the indica- 
tions presented. 

VACCINIA. 

(Cow-pox. Ger. } Kuhpocken; Fr., Vaccine.) 

The limits of this volume forbid a discussion of the interesting 
questions concerning the relations of cow-pox as it occurs spontane- 
ously in the milch cow, to human variola. A careful collation of the 
results obtained by a large number of vacciniculturists of recent days 
renders it clear that it is a matter of great difficulty to transmit variola 
from man to the heifer ; that where this rare result is obtained the 
lymph derived from the lesions on the udder or the belly of the animal 
is liable to produce variola when retransmitted to man ; and that spon- 
taneous cow-pox seems fittest to furnish a lymph which is safely inoc- 
ulable in generations to the human race. 

Of greater importance is it to note that, either by arm-to-arm vac- 
cination as was formerly extensively practised, or by the use of the 
animal virus which is now well-nigh exclusively employed, there has 
been conferred upon millions of human beings a degree of protection 
against variola the value of which is beyond estimate. In both methods 
the lymph is originally derived from the female of the bovine race, 
preferably during the puerperal state, and its sources are the vesicular 
lesions of vaccinia spontaneously arising or artificially cultivated about 
the teats, udder, and adjacent parts. The introduction of this lymph 
into the skin of the human subject is termed " vaccination." 

The operation of vaccination should eliminate to the largest extent 
the possibility of transmitting any other contagious disease than the 
one intended. With this object in view, no better instrument can be 
devised than a clean needle, one which has been properly disinfected 
and not previously employed for any purpose. The skin of the part 
selected for vaccination being first cleansed antiseptically and sub- 
jected to slight tension by the left hand, the vaccinator should scratch 
or scrape off the epidermis with the needle, held in the right hand, 
by a series of parallel and crossed strokes, so as to make three or 
four superficial erosions three inches or more apart. Each of these 
multiplex wounds should have the size of the nail of the little finger, 



VACCINIA. 189 

and should in no case bleed, but merely ooze with serum slightly tinged 
with blood. At such points the lymph, preferably extruded by air- 
pressure from a slender glass-tube in which it has hermetically been 
sealed, is to be rubbed in slowly and thoroughly. 

Between the third and the fourth day after a successful vaccination 
of the unprotected a light-reddish, pin-head-sized maculo-papule rises 
at each inoculated point. Between the fifth and the sixth day it 
becomes transformed into a translucent, well-dis'tended, occasionally 
umbilicated vesicle, which, when single, may attain the size of a finger- 
nail. Springing from the multiplex abrasions described above, a 
minute papule usually forms at each point of intersection of the crossed 
lines produced by the scratching with the needle, and the subsequent 
vesicles coalesce, thus forming by the sixth day a compound lesion of 
rather peculiar aspect. It appears often as a small-coin-sized plaque, 
elevated to the extent of a line or more beyond the general level of the 
skin-surface, with a rim formed of numerous discrete or confluent 
vesicles, which in either case are closely set together. The compound 
plaque seems to develop afterward as a single lesion, its centre being 
depressed. After the ninth day the fluid becomes opalescent, and 
desiccates in a reddish-brown crust, which, examined in section in a 
good light after it is completely dried, exhibits a smooth, homogeneous, 
shining appearance with a color having the shade of amber. . The base 
of the lesion, single or compound, is usually very distinctly indurated. 

Fully as important as any of the metamorphoses of this lesion is 
its rosy-red areola, in the absence of which it has been held that there 
is not proper protection. The areola, which endures from about the 
fifth to the tenth day, completely encircles the compound vesicle in 
the form of a halo having a diameter of several inches, the tissue it 
invades being often slightly tumid. When the pathological process in 
the focus of this areola is intensified, either as the result of the irritant 
character of the virus or from extrinsic causes (undue exertion of the 
vaccinated part), the areola may spread down the arm or over the 
thigh or leg and eventually cover a dense, brawny, and deeply red- 
dened integument. Dermatitis, erysipelas, lymphangitis, adenopathy, 
and severe grades of inflammation of the subcutaneous tissues may for 
similar reasons complicate the process, which may terminate by central 
sloughing, ulceration, slow repair, and the production of an atypical 
cicatrix. Ordinarily the subjective phenomena are limited to a mild 
or annoying itching of the vaccinated surface ; in other cases severe 
burning pain, a feeling of tension, well-marked adenopathy of the 
lymphatic glands in the vicinity and even sympathetic fever may be 
aroused. 

The acme of a successful vaccination is usually attained between the 
tenth and the fourteenth day, after which the symptoms of the dis- 
order gradually subside, the crust falling, if undisturbed, in the course 
of the ensuing week. When "animal" virus is employed the duration 
of each of these stages of the disease is usually somewhat prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually as- 
sumes the dead-white appearance of scars in general. When typical 
it is slightly depressed, circular, not irregular nor deformed by ridges, 



190 INFLAMMATIONS. 

cords, or bands, and " foveolated," exhibiting a series of peripheral 
pits or depressions, each of which represents the site of a former 
minute vesicle of simple type. The degree of protection is based in 
part upon the multiplicity of typical cicatrices. 1 

The complications of vaccination are due : first, to the character of 
the virus employed ; second, to the character of the soil in which it is 
implanted ; and, third, to the external accidents to which the vaccine- 
lesion is subjected. Respecting the first of these sources, there are few 
contagious diseases beside syphilis which may be transmitted by vac- 
cination. When this accident occurs it may be due either to syphilis 
in the vaccinifer or to the use of instruments soiled with infectious 
secretions. The lymph from a typical vaccine-vesicle upon the skin 
of an intensely syphilitic vaccinifer will necessarily transmit syphilis if 
accidentally it be commingled with either blood or the products of 
inflammation at the base of the pock. The stage and intensity of the 
disease in the vaccinifer are elements which cannot be ignored in fore- 
casting the issue. The vaccine-lesion may complete its career during 
the incubative period of the initial sclerosis, the existence of which at 
the site of vaccination is commonly declared later by induration, ulcer- 
ation, pigmentation, and axillary adenopathy. The occurrence of a 
generalized syphiloderm before the chancre of vaccination is completely 
healed may be the first symptom to arouse suspicion. The popular 
impression regarding the frequency of this accident is erroneous. The 
rarest of all modes of transmission of syphilis is that by vaccination. 
In all such cases the possibility that the syphilis may be hereditary 
and its symptoms simply coincident in point of time with those of 
vaccinia, should not be forgotten. It is possible that lepra and tuber- 
culosis may thus be transmitted, but such accidents are exceedingly 
rare. 

Exceedingly dangerous is that vaccine-virus, however good its early 
character, in which decomposition or putrefactive changes have oc- 
curred after exposure, in a liquid form, to the action of heat and the 
atmosphere. Vaccination with lymph thus changed has rapidly been 
followed by fatal results, in consequence of the supervention of pyaemia, 
septicaemia, or gangrene. 

Complications of vaccinia, due to the character or predisposition of 
the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or the prejudiced to the causes just 
considered. Post hoc ergo propter hoc is the sole logic of the unin- 
formed. In this way each of a series of maladies has been ascribed 
to " impurities " and " humors " introduced by vaccination. The argu- 
ments used in support of these assumptions are without basis in the 
most of cases. The cutaneous symptoms which may be awakened by 
vaccination are numerous. It will be remembered that the contents 
of the typical vaccine-vesicle are auto-inoculable, and that thus the 
scratching by young patients may produce an abundant crop of typical 
or torn vesicles upon the arms, legs, thighs, hands, and fingers. But 
vaccination may awaken in the patient, as explained above, a latent 

1 Welch-Sckamberg, " The Characteristics of Genuine Vaccinia,'' St. Louis Med. and 
Surg. Jour., 1902, lxxxii., p. 199. 



VACCINIA. 191 

syphilis, as also a list of cutaneous disorders not contagious in 
character. Thus, an erythema (roseola vaccinia, vaccinola, etc.), 
eczema in many of its forms, and other exudative processes may be 
aroused first in the integument by the turbulence of a successful 
vaccination. 

These rashes may become generalized/and may even assume a for- 
midable appearance. They may appear at any time from the second 
to the fourteenth day after vaccination. A scarlatiniform rash, dif- 
fused or in patches, is described by some authors as occurring in this 
way, accompanied by mild fever, and resembling German measles. 
Similarly generalized eruptions, resembling erythema multiforme, ery- 
thema scarlatiniforme, eczema, psoriasis, pemphigus, urticaria, impetigo 
contagiosa, varicella, and other cutaneous disorders, may appear for the 
first time within the limits named above. They usually disappear 
within a brief time after the vaccine-vesicle has completed its involu- 
tion, and may be followed by slight desquamation or pigmentation. 
Very rarely vaccinia is followed by erysipelas, by purpuric symptoms, 
and by the development of lupus-nodules -at the site of inoculation. 

Vaccinia Hemorrhagica is a term descriptive of a complication 
of either the vesicle of vaccinia or of lesions surrounding the latter. 
In these cases there is hemorrhage into the vaccine- vesicle or the 
development of petechia? in its neighborhood. As a result of unclean- 
liness, not only may erysipelas be communicated as noted above, but 
septic infection, gangrene, tetanus, and other affections may originate 
at the site of a vaccine-vesicle. 

Anomalies of the vaccine-vesicle occasionally are noted as to shape, 
career, and resulting cicatrix, which are difficult to explain. Thus, 
the papulo- vesicle may not exhibit an umbilicated centre, or may com- 
plete its course within unusually short limits; or a harmless ulceration 
may progress beneath its crust, requiring a week, or even more, for 
complete cicatrization. The so-called " raspberry-sore " results from 
coalescence of small papules, so as to form a pigmented tubercle. The 
scars resulting from many of these irregular and non-protective results 
of vaccination usually form atypical cicatrices, being, in one case, small 
palm-sized, deforming, corded, and representative of large tissue-loss ; 
and, in another case, irregular and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of 
the lesion are usually inflammatory in character. The excessive use 
of the vaccinated arm in labor and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis and even ulcerative changes in the site of the in- 
oculation, as a result of the intensity of the process. For these acci- 
dents rest is essential, with the free use of a dusting-powder over the 
inflamed surface. In exaggerated cases lotions of lead-water and opium 
may be employed. These conditions usually are relieved without 

1 Burton, L., Arch., 1903, lxv., p. 289; Piffard, Jour. Cutan. Dis.,1899, xvii., p. 467; 
Morrow, Brit. Jour. Derm., 1901, xiii., p. 433; Freeman, Ibid., 1902, xiv., p. 186; Stel- 
wagon, Jour. Amer. Med. Assoc., 1902, xxxix., p. 1291 ; Towle, Boston Med. and Surg. 
Jour., 1902, cxlvii., p. 269; Heidingsfeld, Jour. Cutan. Dis., 1902, xx. } p. 67, 



1 92 INFLAMMA TIONS. 

difficulty as soon as the part is put to rest. The atypical scar which 
results seems to be in such cases as protective as others, if only the 
accident have occurred to a typically progressing lesion with distinctly 
perfect areola. Vaccine-cicatrices are to be distinguished in anomalous 
situations from maculae atrophica?, the scars of syphilis, and other scar- 
leaving disorders. 

Bullous Dermatitis following Vaccination, at times with 
fatal results, occurring both in infants and adults, is a disorder of spe- 
cial importance. Cases of this type have been recorded by Bowen, 1 
Howe, 2 and others. None of those reported by Bowen proved fatal. 
The bulla? appeared on the trunk in adults, though in children this re- 
gion was spared ; and were isolated or confluent, of different dimensions 
from that of a split pea to the size of small coin, often associated with 
oedema, purulent secretion from the parts invaded, and the formation 
of blackish crusts, the lesions in certain cases sparsely, in yet others 
abundantly distributed over the entire body-surface. About five weeks 
after vaccination the exanthem appeared in the dangerous cases, those 
resulting fatally suffering from the usual complications of exhaustive 
disease. Some of the patients were unmistakable subjects of chronic 
alcoholism. The connection between the vaccination and the subse- 
quent eruption is not definitely established. We have had two cases 
in children and two in adults. All eventually recovered. 

Generalized Vaccinia (vaccinal eruptive fever) usually results 
from a non-cutaneous introduction of vaccine virus; and is characterized 
by the production of vesicles of vaccinia in crops, which resemble 
strongly the lesions of variola. Supernumerary vesicles form, at times 
on the mucous surfaces of the mouth, with febrile symptoms and sub- 
sidence of the eruption in about three weeks. 

Pathology. — In the vaccine vesicle, according to Unna, the epi- 
thelium undergoes ballooning as in variola and varicella, but in the 
first-named affection the two forms of degeneration, " reticulating col- 
liquation " and " ballooning/' are peculiarly commingled. The greater 
prominence of the ballooning may be due in part to the juvenile char- 
acter of even the oldest cells. The existence of an inoculation-wound 
has a marked influence on the microscopical picture, the resulting 
fissure being filled with blood-disks inside the horny layer, which is 
somewhat thickened. In vaccinia, as in the two maladies which path- 
ologically it most resembles in its lesions, the formation of the vesicle 
is by chambers, the septa consisting of collections of cells (granular and 
others) which seem to be the remains of the sweat-pores. 

Micrococci have been recognized by Cohn in vaccine-lymph. These 
have been named " micrococci vaccinae," but their relation to similar 
organisms discovered in the blood and tissues of variolous patients has 
not been determined. Wolff 3 claims to have cultivated these organisms 

1 Jour. Cutan. Dis., 1901, xix., p. 401. 

2 Ibid., June, 1903, xxi., p. 254. 

3 Berlin, klin. Wchnschrft., January 22, 1883. 



ERYTHEMA HYPERMMICUM. 193 

through fifteen generations. Strauss demonstrated their existence in 
the vaccinal pustules of the calf. 1 

Lipp, of Gratz, reported to the International Medical Congress, in 
London, that he had recognized great similarity, if not identity, be- 
tween the micrococci of vaccinia and those of variola that he had 
cultivated to the second generation, but had then been unsuccessful in 
producing inoculation-effects. These organisms were always arranged 
in groups of four or multiples of four. 

Steinhaus 2 reports that Unna's ballooning and reticular degenera- 
tions play no part in the formation of the pock in animals. The process 
is, instead, Ziegler's dropsical degeneration with typical mitoses, but 
without division of the cell-nucleus. 

Treatment. — The management of the severer types of vaccinia and 
of the complications of the disease is to be conducted in accordance 
with the principles of treatment described in connection with derma- 
titis venenata and acute eczema. 



ERYTHEMA. 

(Gr. epvdrjfj,a y redness. ) 

(Rose Rash. Fr., Erytheme ; Ger., Hautrothe.) 

Erythema is, strictly speaking, a mere redness of the skin due to 
congestion of the cutaneous vessels. Much confusion has arisen from 
the fact that the term is used to indicate a mere symptom, and is also 
applied to two fairly well-defined groups of cutaneous diseases. Red- 
ness of the skin, varying greatly in its intensity, duration, and distri- 
bution, is seen in many different conditions and diseases of the integu- 
ment and of the general economy. In the so-called " idiopathic 
erythemas " the redness may be the sole symptom recognizable, but it 
is usually produced by some definite internal or external form of irri- 
tation, or is symptomatic of systemic disease. Erythema may simply 
be hypersemic and be due to a congestion, active or passive, of the 
cutaneous blood-vessels, or the process may go on to exudation and 
inflammation. From a pathological point of view it is evident that no 
sharp line can be drawn between erythema hypersemicum and erythema 
exudativum, yet for clinical purposes it is convenient to make this dis- 
tinction. 

ERYTHEMA HYPER.EMICUM (seu SIMPLEX). 

Erythema simplex is a coloration of the skin in various shades of 
redness, temporarily disappearing under pressure, the lesions differing 
in size and shape according to the extent and degree of the hyperemia 
by which they are induced. . 

Simple erythema is seen in the phenomenon known as blushing. 
Ordinarily this is a purely physiological and transitory hyperemia due 

1 See Magnan, loc. cit. 

2 Gaz. Lekarsk., 1898, xviii., p. 274. 

13 



1 94 INFLAMMA TIONS. 

to emotional causes. Cases occur in which the hyperemia thus 
induced persists for hours, together with palpitation and other evi- 
dences of circulatory disturbance. Here the erythema is symptomatic 
of either physical or mental disorder. With the former may be classed 
those disorders in which portions of the face remain flushed after eat- 
ing, exercising, exposure to heat, etc. 

Under idiopathic erythema, have been classed simple forms of 
erythema for which no cause is recognized. In the great majority of 
cases a careful search will disclose the disease or condition of which 
the erythema is but a symptom. The cause may be found in external 
irritation too slight and too transient to produce a dermatitis, in dis- 
turbances of the alimentary canal, in the nervous irritability of children 
due to "teething," in a drug-idiosyncrasy, or in one of many other 
derangements of the general economy. Again, the erythema may be a 
more or less important diagnostic symptom of graver constitutional 
disease, as in the exanthemata, typhoid fever, etc. The color in ery- 
thema may vary from a delicate pink or rosy shade to a dark-reddish 
hue; it may be transitory or persistent, and may be limited to circum- 
scribed points, or macules, or be displayed in diffuse, ill-defined areas. 
The character, duration, and distribution of these rashes when due to 
simple causes often depend largely upon the peculiarity of the indi- 
vidual. The same source of disturbance or irritation may produce 
different effects on the skins of different persons. 

Erythema traumaticum is the result of friction, rubbing, pressure, 
scratching, or similar external contacts. It is observed, for example, 
in the part pressed by the pad of a truss ; in the colored circle left 
about the leg where a tight garter has been worn ; and the sides of the 
nose where pressure is exerted by a newly applied pair of eye-glasses. 
These traumatic hyperemias are readily converted into exudative 
affections if the traumatism be long continued. Intermittent pressure 
upon the skin permits restoration of the vascular equilibrium, and the 
integument responds to the demand made upon it by increasing in 
thickness ; continuous pressure, on the contrary, admits of no such 
restoration, and the tissue finally becomes thinner, and yields before 
the agent inflicting the injury. Inflammation resulting in ulceration 
may finally supervene. 

Erythema Caloricum. — Extremes of heat and cold, either natural or 
artificial, are sufficient to induce transitory redness of the skin-surface. 
In the erythema induced by solar heat (Erythema Solar e) there is 
frequently an increase in the pigmentation of the surface, as in the 
production of freckles and " tan " in persons whose skins are reddened 
by the sun. The darker, brownish, and chocolate- colored stains of the 
hands and face thus are induced. 

Erythema ab Igne occurs in annular and odd-looking gyrate 
patches on the anterior surfaces of the legs in cooks, firemen, and stokers, 
and in persons exposing that portion of the body to the direct action of 
heat. The annular patches may be several centimetres in diameter 
and vary in shade from a light to a deep red or even a purplish tint, 
intense, often permanent pigmentation resulting as the erythema sub- 



SYMPTOMATIC ERYTHEMA. 195 

sides. Perry 1 believes that the phenomena are due chiefly to a blood- 
disintegration occurring in and around the walls of the plexus of super- 
ficial veins. ' He adds that the name ephelis ab igne better describes 
the condition. 

Erythema Venenatum. — A number of chemical substances, dyes, 
and vegetable poisons are capable of producing transient hyperemia 
of the skin. Among these may be mentioned cantharides, capsicum, 
mustard, anilin, chloroform, ether, arnica, and several of the essential 
oils. 

Erythema Gangrenosum. — Under this title several singular affections 
of the skin have been described, in which erythematous patches 
appeared and were followed by greater or less extensive destruction of 
one or more of the several layers of the skin. T. C. Fox, in a descrip- 
tion of the appearances in two cases of the affection under his observa- 
tion, concludes that these patches are the symptoms of a feigned disease, 
or of one produced artificially for the purpose of exciting sympathy, 
etc. The majority of these cases are more properly described with 
dermatitis gangrenosa. 

Erythema Laeve is an obsolete term once employed to designate the 
shining redness of the skin in oedema of the lower extremities following 
any disorder sufficient to induce local tumefaction. 

Erythema Paratrimma is a term once employed for the form of deep 
and lurid redness preceding the formation of a bedsore, an accident 
which under modern methods of nursing is as obsolete as the name 
once given it. 

Erythema Fugax is a term applied to a transitory redness of 
the skin, usually occurring in small areas, which appears and dis- 
appears very much as do the lesions of urticaria ; in fact, it may well 
be considered a mild form of urticaria in which typical wheals are 
absent. 

The Diagnosis of simple erythema is not difficult, since without 
exudation there is an absence of all other elementary or secondary 
lesions of the skin. The difficult point in diagnosis is to establish the 
cause. 

The Treatment of most of the erythemas depends entirely on the 
underlying cause. For the condition of the skin little if any treat- 
ment is necessary. A dusting-powder is often of service, and if there 
be itching or burning an antipruritic or soothing lotion may be indi- 
cated. Ointments are rarely required. 

SYMPTOMATIC ERYTHEMA. 

This may be of either active or passive form. A long list of phys- 
iological and pathological causes operating upon the system at large are 
capable of inducing active symptomatic hyperemia of the skin. The 
large majority of these erythemas are toxic in origin. The redness 
may be generally diffused, or occur in surface-mottlings and markings 
of various sizes and shapes. Thus, the skin of the face may be red- 
1 Brit. Jour. Derm., 1900, p. 94. 



196 INFLAMMATIONS. 

clened intensely in a paroxysm of rage ; and that of the limbs of a teething 
child be covered with rosy maculations in consequence of the reflection 
to the surface, through the medium of the nervous system, of the irri- 
tation induced by the eruption of a tooth. In consequence of the rosy 
tint assumed by several of these rashes they have long been termed 
" roseola," a name which to-day is held to describe a symptom rather 
than a disease. The word roseola is still associated in the minds of 
many with the earliest syphiloderm, but that eruption is now designated 
by the best authors as the erythematous, or macular, syphilide. 

Roseola infantilis is sometimes described as a distinct affection 
in which there are fever and constitutional disturbance lasting a few 
hours or even a few days. The exanthem varies greatly in extent and 
distribution. It is usually macular or punctate, but may be finely 
papular ; it is most common on the trunk, but may appear on other 
parts of the body ; it may closely simulate scarlatina or measles. It is 
probable that these phenomena are always the manifestations of some 
systemic or local disorder, and not, as the name would indicate, due to 
a definite disease. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a prompt efflorescence of 
this character. A lurid erythema of the axillary or the inguinal re- 
gion may precede by several days the eruption of confluent variola. 
Cholera, cerebrospinal meningitis, diphtheria, enteric and other fevers 
are thus at times accompanied, preceded, or followed by rashes. A 
study of these rashes is of the utmost importance to the diagnostician. 
Children who are really susceptible to the disease are often supposed 
to possess an immunity from scarlatina, as the symptomatic erythema 
previously displayed was misconstrued. Vaccination may be followed 
in from one to eight or nine days by a macular or more diffuse ery- 
thema of the trunk and extremities, usually accompanied by some 
febrile reaction. 

Symptomatic passive erythema is usually characterized by a cyan- 
otic, purplish or darker hue of the integument, resulting largely from 
accumulation in excess of carbon dioxide in the blood. The tempera- 
ture of such skins is either normal or below the normal standard, as in 
those cases in which gangrene ensues. A long list of conditions may 
be named in which these symptoms are noted, including derangement 
of the blood-vessels from imperfect innervation, direct pressure, or 
disease of the heart or vascular walls. 

These erythemas may be either circumscribed in area or general- 
ized. The term " livedo " is applied to circumscribed regions of passive 
erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this 
form of disease. The so-called " symmetrical gangrene " of the fingers 
belongs to the same category. Cardiac cyanosis, or Morbus Coeruleus, 
is a name given to a generalized dark-blue discoloration of the entire 
surface, due to continued patency of the foramen ovale. 



SYMPTOMATIC ERYTHEMA. 197 

Erythema Scarlatiniforme. 1 

(Scarlatinoid Erythema, Desquamative Scarlatisiform 
Erythema, Scarlatinoid e, Erythema Punctatum, Roseola 
Scarlatiniforme, " Scarlet Bash," Dermatitis Scarlatini- 
formis Recidivans. Fr. y Erytheme infectueux.) 

Erythema scarlatiniforme is a name given to an eruption arising 
from a large number of causes and varying considerably in character, 
but having a tendency to simulate the rash of scarlatina. This condi- 
tion has been described as an idiopathic disease, but it has so often been 
demonstrated to be a symptom only of other disorders that its exist- 
ence as an independent affection may well be doubted. 

Besnier, Brocq, and other French authors describe an erythbne sca?*- 
latino'ide, which is acute in type, and which is always secondary to 
other infectious diseases, to auto-toxaemia, or to medicinal or food-tox- 
aemia ; and an erytheme scarlatiniforme desquamatif, which is subacute 
in type, and which may be idiopathic, secondary to other infectious 
diseases, or be produced artificially by drugs. While it is often clin- 
ically convenient to make a distinction between acute and subacute 
forms of scarlatiniform erythema, there are no good pathological or etio- 
logical grounds for making such distinctions, since a given drug or 
given form of intoxication may produce the acute type in one individual 
and the chronic form in another. 

Symptoms. — In the acute type, which is the more common of the 
two forms, the rash may be preceded by a day or two of fever and 
other evidences of constitutional disturbance, or it may appear sud- 
denly without premonitory symptoms. The exanthem spreads rapidly 
and in a few hours, or at most in two or three days, reaches its full 
development. The eruption is usually universal, or at least general- 
ized, but may be more limited in distribution. The rash may be 
punctiform, macular, or diffuse, and the color may be any of the shades 
of red, but it is usually a bright scarlet. In some instances it has all 
the appearances of a typical scarlatinal rash, except that it may begin 
on any part of the body, often sparing the face, and that desquamation 
begins much earlier (three or four days after the onset of the malady) 
than in scarlatina. There are usually some fever, malaise, and other 
constitutional disturbances that may vary greatly in intensity, depending 
upon the disease of which the exanthem is a symptom. The mucous 
membrane of the mouth, the tongue, and the fauces may be reddened 
or be denuded of epithelium, but the characteristic strawberry-tongue 
of scarlatina is wanting. The nails and hair may be shed, but only in 
exceptional cases. 

Desquamation usually begins in from two to six days, sometimes 
before the disappearance of the rash, and it may even occur on sur- 
faces which had not perceptibly been reddened. The scales are usually 
furfuraceous, but they may be large and abundant ; in rare instances 
the entire epidermis of the hand may be shed in glove-like form. Com- 
plete involution may require from a few days to several weeks. Rarely 
1 For bibliography, see Dermatitis Exfoliativa. 



198 INFLAMMA TIONS. 

the process terminates in a persistent exfoliative dermatitis. Recur- 
rences are common, but in some instances may be prevented by the 
discovery of the exciting cause. 

The subacute forms of scarlatiniform erythema dhTer from those 
described above in that constitutional disturbances are less, the rash 
has a greater tendency to be universal, and, together with the desquama- 
tion, may persist for weeks or for months, recurrences being frequent. 
Occasionally cases are found in which recurrences are so frequent as to 
make the condition practically continuous and clinically indistinguish- 
able from the milder forms of dermatitis exfoliativa. 

Etiology. — Idiosyncrasy is a most important factor in the etiology 
of those forms of erythema which appear in certain predisposed indi- 
viduals as a result of causes totally insufficient to produce the same 
phenomena in most persons. The exciting factor is usually, if not 
always, some form of toxaemia. Among many causes reported are : 
infectious diseases, septicemic conditions, toxaemias of varied origins, 
peritonitis, rheumatism, ague in children, gonorrhoea, abscess, empyema, 
ursemia, tuberculin-injections, sewer-gas poisoning (Crocker), certain 
articles of food, and many drugs. The causes are sometimes external, as 
when following mercurial inunctions, exposure to high temperature, etc. 

Diagnosis. — It is most important to distinguish this rash from that 
of scarlet fever. Commonly the diagnosis is not difficult, as in ery- 
thema scarlatiniforme the constitutional symptoms are slight ; the rash 
appears rapidly, beginning on any part of the body ; the lesions are 
exclusively cutaneous ; desquamation begins early and is extensive ; 
the fauces though red are not swollen ; and there is absence of the 
strawberry-tongue and of all history of contagion. Occasionally the 
rash may closely resemble that of measles or rotheln, but the history 
of the case and the absence of other symptoms peculiar to these affec- 
tions should make the diagnosis clear. As a rule, an examination of 
the rash alone is insufficient, and a diagnosis of erythema scarlatini- 
forme should not be made until the other exanthemata have been con- 
sidered and excluded. 

Treatment. — This depends entirely on the underlying cause or con- 
dition. Toxins present should be eliminated as rapidly as possible. 
The rash itself rarely calls for treatment. If there be itching or burn- 
ing sensations, a simple dusting-powder, with or without an anti- 
pruritic or a soothing lotion or ointment, may be used to make the 
patient more comfortable. 

Prognosis. — As a rule the condition disappears entirely and the 
general health of the patient is unaffected. Recurrences are frequent, 
and some cases terminate in a more or less persistent exfoliative der- 
matitis. 

Shedding of the Skin (Deciduous Skin, Keratolysis). — 
Cases are reported of individuals whose skin is shed periodically 
like that of a serpent. We had the privilege of observing the case 
reported by Frank and Sanford 1 during one of the periods in which 
the man's skin was exfoliated. The patient was thirty-three years of 
1 Amer. Jour. Med. Sci., Aug., 1891. 



ERYTHEMA PERNIO. 199 

age, well formed, and apparently in perfect health. No cause for the 
skin-shedding could be found. He stated that ever since he could 
remember, and certainly since he was eight years old, he had had 
peculiar symptoms which have begun between 3 and 9 P. M. of the 
24th of July each year. He would suddenly experience a feeling of 
lassitude or weakness, followed by muscular tremors, nausea, and vom- 
iting, with rapid rise in temperature. Accompanying these symptoms 
the mucous membranes were hypersemic ; the skin was hot, dry, and 
without perspiration. After three or four hours the acute symptoms 
began to subside, but the skin remained red for thirty-six hours or 
longer. The shedding of the skin began usually on the second or third 
day, and was completed in from three to ten days. On the occasion 
on which we observed the man, the mucous membrane of the tongue 
and mouth exfoliated on the third day ; the epidermis was removed 
from the trunk and arms in large sheets on the sixth day ; and from 
the remainder of the body, except the hands and feet, within the next 
three days. Complete casts of the hands and feet were shed by the 
seventeenth day, and the nails all came off within a month from the 
beginning of his illness. 

This case was observed the following year and reported by Sligh, 1 
who evidently had not seen Frank and Sanford's paper. Sligh's 
report coincides with the facts we observed. Similar cases are reported 
by Stelwagon, 2 Stone, 3 and others. 



ERYTHEMA PERNIO. 

(Pernio, " Chilblains." Ger., Frostbeule ; Fr., Engelure.) 

This is a form of erythema occurring in persons having a feeble 
circulation or strumous diathesis, usually in the young and the very old. 
Permin 4 calls attention to its frequent occurrence in the tuberculous. 
The redness is most conspicuous, as a rule, on the hands and feet, merely 
because of the distance of these organs from the centres of circulation. 
The redness is of either a light or a dusky shade ; is accompanied by 
tenderness, itching, and burning sensations, especially when the part is 
brought near an artificial source of heat ; and may be the origin of 
exudative and other affections of the skin, though the ulceration and 
sloughing which occur in extreme cases are really the results of freez- 
ing the organs rather than of simple exposure to cold when the circu- 
lation is impaired. 

The Diagnosis is readily made when it is observed that the redness 
disappears on pressure, and also that the parts are actually cool rather 
than hot, the coolness being appreciable by the touch. Not rarely 
they are both cool and moistened with sweat. Pernio may closely 
resemble an early stage of lupus erythematosus, but the latter does not 

1 Internal. Med. Mag., 1893, p. 463. 

2 Diseases of the Skin, p. 143. 

3 Jour. Amer. Med. Assoc., 1900, ii., p. 557. 

4 Hospitalstidende, 1903, xviii., Copenhagen (abstr. in Brit. Jour. Derm., 1903, xv., 
p. 376). 



200 INFLAMMATIONS. 

vary regularly with the seasons as does pernio, which usually disap- 
pears in summer and reappears in winter. The two conditions are at 
times related, as individuals are seen with pernio of the hands or the 
feet, and lupus erythematosus of the face. Cases are recorded in which 
the site of a recurring pernio has become the seat of a typical lupus 
erythematosus. 

The Treatment of pernio should be directed to improvement of the 
circulation and the general health. Warm clothing to protect the af- 
fected parts together with active exercise may do much to prevent re- 
currence of the disease. Fowler's solution is considered a prophylactic 
if given in small doses at the beginning of cold weather. The local 
treatment is by brisk friction and stimulating lotions, such as camphor- 
ated soap-liniment ; acetous, spirituous, and vinous lotions ; or the use 
of the ordinary " bay rum " of the shops. Afterward the parts should 
be painted with a 50 per cent, solution of ichthyol, well dusted with 
boric acid, and bandaged or wrapped in cotton. The severer forms of 
the disease are considered under Dermatitis Calorica. 



ERYTHEMA INTERTRIGO. 

(Intertrigo, Eczema Intertrigo, Chafing.) 

Erythema intertrigo is a hypersemic condition of those cutaneous 
and muco-cutaneous surfaces which are in constant apposition, and 
between which there is a hypersecretion or retention of sweat. 

Symptoms. — The erythema is limited to portions of the integument 
which lie in contact with each other, and is subject to certain modifica- 
tions. The sites of such contact in the human body are the axillae, the 
groins, the cleft between the nates, the intermammary and inframam- 
mary spaces in women, the superior and inner faces of the thighs, the 
scroto-femoral and the labio-femoral clefts in the sexes respectively, the 
flexures of the joints, and in especially obese individuals all those parts 
where the integument is thrown into fleshy folds, as about the necks of 
infants, and even over the crest of the ilia in fat women. In these 
localities the disorder, beginning as an erythema traumaticum, proceeds 
by its irritative effects to stimulate the secretion of sweat, which is 
freely poured out between the adjacent folds of the skin, and may there 
temporarily be imprisoned. The surface, heated and reddened, is also 
somewhat macerated by the effused perspiration, and the latter, when 
chemically altered, as it is frequently under these circumstances, adds 
still further to the original disorder. The ground is thus well pre- 
pared for an exudative process, which not infrequently supervenes in 
the form of a dermatitis or an eczema marginatum ; but the disorder may 
be limited to mere hyperemia with hyperidrosis, and disappear before 
the supervention of actual inflammation. 

The sensations produced are those of heat and tenderness. When 
the parts in contact are separated the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macerated 



ERYTHEMA INTERTRIGO. 201 

epidermis become evident. One such abrasion is always especially 
significant. It is the linear and superficial excoriation which marks 
the line of deepest contact of the two apposed surfaces of the skin at 
the bottom of the angle formed by the two. An offensive odor usually 
proceeds from the part in consequence of the secreted fluid. The secre- 
tions of an intertrigo stain, but do not stiffen, the linen of the patient, 
and they thus differ from the serous fluid poured out in an exudative 
dermatitis. 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture — these causes occasionally cooperating. The heat may merely 
be that of the natural temperature of the body, or it may be increased 
by that due to season and climate. The friction also may merely be 
that originating between the surfaces in apposition, or it may be in- 
creased by clothing or other articles worn next the skin. The moisture 
which produces maceration of the epidermis is that originating in the 
perspiratory follicles, their secretion being doubtless stimulated by the 
heat and friction. The interchange of operation of these three factors, 
lastly, is shown by the fact that friction, if severe, is capable of increas- 
ing the temperature of the part to which it is applied. 

As aggravating causes may be named other physiological secretions 
and excretions retained in contact with the surfaces affected with an 
intertrigo. Thus, the feces of the infant left in contact with its nates 
upon the napkin ; the urine of the old man with paralysis of the bladder 
or with " overflow" from prostatic disease; the milk of nursing women 
dribbling over the breast to the inframammary region ; retained lochial, 
menstrual, and similar discharges, are all efficient in this regard, and 
are particularly liable to induce that form of dermatitis to which the 
intertrigo then plays a subordinate part. Fleshy and gouty persons 
chiefly suffer from these accidents. 

Diagnosis. — The recognition of a simple erythema intertrigo is a 
matter of no difficulty if regard be had to the exciting and aggravating 
causes enumerated above, and to the special localities in which such 
hyperemia generally originates. If an eczema or a dermatitis super- 
vene, the fact will appear from increased subjective sensation (usually 
severe itching), from an infiltration of the affected integument, and 
from the appearance of those lesions and discharges which are signifi- 
cant of these forms of inflammation of the skin. It must be remem- 
bered that transition from a simple erythema to a dermatitis of these 
regions is of frequent occurrence. Erythema intertrigo may occur as 
a mild form of eczema seborrhoeicum. 

The special sites of preference of intertrigo are those of the disease 
named by Hebra " eczema marginatum," or ringworm as it occurs upon 
the parts of the thighs covered by the " reinforcing " patch in the 
trowsers of cavalrymen. The disease is properly named " tinea cir- 
cinata cruris," though it is found also about the axillae, the buttocks, 
and the groins of both sexes. Here the disorder, however, is of the 
exudative type, and, moreover, is distinguished by a characteristic 
" festooning " of the elevated border marking the advancing limit of 
the disease. The microscope, by revealing the existence of a fungus, 
will, of course, put an end to any doubt. In intertrigo the most 



202 INFLAMMATIONS. 

marked evidence of disease is to be recognized in the deeper parts of 
the cleft between the two adjacent skin-surfaces, while in tinea cir- 
cinata cruris the growth of the parasite is most active at the advancing 
border of the patch, which is, moreover, perceptibly elevated above the 
sound skin. 

Treatment. — Intertrigo is an exceedingly common affection of the 
skin, and it occasionally proves of great annoyance to those suffering 
from it. The skill of the young practitioner is often tested early in his 
professional career by his management of such cases ; and not a little 
may depend upon the success with which he is rewarded. Gouty 
patients always require limitation of the diet, and often also medication 
with alkalies and mercurial cathartics. 

The affected surfaces should gently be cleansed by ablution with 
soap and warm water, and the offensive odor of the secretions remedied 
by the addition to the water of a weak solution of formalin, of carbolic 
acid, or of the dilute liquor sodse chlorinatse. The parts are then to be 
carefully dried with a freshly laundered towel or a soft handkerchief, 
and afterward one of the dusting-powders very thoroughly applied. 
To be of service, these powders must be impalpable, and, if compounded 
by a druggist, be sifted through fine silk bolting-cloth. The articles 
chiefly used for this purpose are zinc stearate with acetanilid, bismuth, 
starch, zinc oxide, French chalk, lycopodium, or, when an antipruritic 
effect is desired, camphor. Combinations of several of these are at 
times effective. The formula of McCall Anderson is highly esteemed : 



M. 



For the purpose of absorbing excessive perspiration magnesium 
carbonate is the most effective of all the powders. 

The following is the formula for a dusting-powder recommended 
by Klamann : 1 



R Zinci oxid. pulv., 


,l ss ; 


16 


Camphorse pulv., 


3jss ; 


6 


Amyli pulv., 


3j; 


32 


Sig. Anderson's dusting- powder. 







R Talc, venet. pulv., 


Zv; 


20 




Acid, salicyl., 


gr. iij ; 




18 


Magnes. ust. subtil, pulv., 


3jss ; 


6 


M. 


Sig. Dusting-powder. 









Finely bolted starch answers well alone or in combination with some 
of the other articles above named. 2 

The affected surfaces of the skin must also be separated in order to 
prevent further friction. A thin strip of lint, antiseptic cotton, or 
medicated wool may be used for this purpose, and must be inserted as 
far as the deeper portions of the cleft in which the secretion chiefly 
forms. Occasionally it will be found useful to anoint this absorbent 
layer with cold-cream salve or with vaselin. Where an astringent effect 
is desired lycopodium or other dusting-powder may be compounded with 

1 Hebam. Kalend., Obstet. Gazette, March, 1882. 

2 Unna's salve-muslins and pastes will be found effectual and neat applications in 
many forms of intertrigo. 



PLATE II. 







Erythema Multiforme Cireinate-type. 






ERYTHEMA MULTIFORME. 203 

tannin, alum, or similar substances. The list of lotions also may at 
times be consulted with advantage. Thus, cologne-water, weak spirit 
lotions, tannin, or aromatic wine, or magnesium carbonate, may each be 
serviceable. Lastly, carron oil (equal parts of lime-water and linseed- 
oil), spread thickly upon linen, will possibly give more relief than other 
articles named, the chief objection to it being the consequent soiling of 
the patient's clothing. 



ERYTHEMA MULTIFORME. 

(Erythema Exsudativum Multiforme. Ft., Erytheme 
polymorphe.) 

Erythema multiforme is an acute, inflammatory, exudative disease, 
characterized by crimson-red or purplish-red macules, papules, or 
tubercles, with the occasional appearance of vesicles or bullae, the 
lesions being variously grouped or isolated, and due usually to some 
systemic disturbance. 

Symptoms. — In this affection the most common lesions are oedema- 
tous-looking macules, flattened papules, and even large flat nodosities. 
Vesicles and bulla? occur in a few cases. While multiformity is the rule, 
one type of lesion usually predominates in each case. The eruption is 
nearly always symmetrical, and occurs usually upon portions of the 
extremities, the forearms, the legs, and the dorsum of the hands and 
feet. It occurs exceptionally on other parts of the body, and rarely 
upon the mucous membrane of the mouth, nose, and conjunctiva. It 
has been seen on the sclerotic. From the beginning the lesions are 
more or less flat, elevated, and cedematous. The eruption, which is 
generally recognized in well-defined patches, usually begins with 
pinhead- to finger-nail-sized macules of a darkish-, bluish-, or purplish- 
red shade that lose their color under the pressure of the finger, and in 
the course of some hours exhibit tumefaction in various degrees, thus 
producing the papules, tubercles, and nodes already described. In 
many cases there is a remarkable tendency to a flattening and widening 
of the lesions to a point, when they closely resemble a floridly tinted 
condyloma. The disease may persist for but a few days, but in severer 
grades it lasts for several weeks or months. Recurrent attacks through 
a period of years are not uncommon. In the height of the exudative 
process there is usually an efflux of the coloring-matter of the blood 
into the skin which is the site of the several lesions, and thus are pro- 
duced the singular shades of reddish black, purple and red, blue and 
red, yellow and orange, black and blue, that are characteristic of 
simple bruises of the extremities when the injury has been sufficient 
to cause extravasation of blood. The lesions occur in various shapes, 
sizes, and shades, a number of names having been used to designate 
their several appearances, that require explanation though they are 
without practical value. 

The exanthem is peculiar in that it is especially likely to develop 
and recur in the spring and autumn, is not capable of being awakened 



204 INFLAMMATIONS. 

to activity by external irritation solely, and is productive of rather 
insignificant subjective sensations (burning and smarting) as compared 
with other rashes of even less brilliant hue. 

Erythema Annulare ( or Circinatum) is characterized by a central 
depression and paling of color, and a peripheral extension of the ery- 
thematous patch in the form of a ring. 

Erythema Figuratum occurs in gyrations formed by coalescence of 
two or more annular circles. 

Erythema Induratum is considered with the tuberculous affections of 
the skin. 

Erythema Marginatum is that form of the disease in which a dis- 
tinctly elevated and defined marginal band is left as the sequel of an 
erythematous patch. 

Erythema Papulatum (or Papulosum) and Erythema Tuberculatum 
(or Tuberculosum) are those forms in which occur lesions respectively 
of a papular or a tubercular type. 

Erythema Urticatum is that form in which there is severe itching, 
and, as a result, scratching of the lesions, with crusts of dark dried 
blood at the summit of each. The crust is surrounded by the light-red 
or bluish-red, flattened or elevated patch characteristic of the disease. 

Erythema Vesiculosum and Erythema Bullosum are exceptional forms 
in which the exudation is sufficient to raise the horny layer of the 
epidermis into larger or smaller serum-containing chambers, which may 
be, as regards the erythematous patch, of central or peripheral situation, 
and Avhich may crown the summit of papule or tubercle. The fluid is 
usually removed by absorption, and is rarely set free by rupture of the 
vesicle or bleb. 

Erythema Iris (Herpes Iris, Hydroa Vesiculeux) is the result of suc- 
cessive erythematous centric lesions, which at times form several dif- 
erently shaded concentric rings. 

At the onset there appear one or several vesicles or vesico-papules, 
which pursue their rapid career in two or three days. Upon the hyper- 
semic ring which surrounds these lesions a second and even a third and 
fourth circlet of similar lesions form, each pushing the areola further 
to the periphery of the patch. The older lesions are in full retrogres- 
sion, while the newer vesicles are in process of evolution ; and the red 
blush which surrounds the earlier lesions is undergoing color-changes 
from vivid to purple and paler hues, while the zone of the latest vesicles 
is assuming its intensest shade. The lesions are pinhead- to pea-sized, 
rather persistent and firm, and terminate more often by resolution than 
by rupture and crusting. The concentric and parti-colored rings may 
make up a single patch an inch or more in diameter, or several such 
patches may form upon the surface of the integument. In the latter 
case the central disk of some of the patches will be seen to be composed 
of confluent lesions. The subjective sensations produced are usually 
trifling. 

Atypical forms occur in which the lesions are developed imperfectly 
from papules, and also in which, in consequence of an unusual exudation 
of serum, bullae appear. These may coalesce or be filled with blood ; 
or hematuria may result, with severe involvement of the mucous mem- 



ERYTHEMA MULTIFORME. 205 

brane of the lips, the tongue, the soft palate, and other parts of the 
mouth, ulceration rapidly ensuing. Cases with these complications 
should really be classified with the grave forms of pemphigus, to which 
they properly belong. 

Erythema Nodosum (Dermatitis Conttjsiformis ; Fr., Eryth- 
eme Noueux) is a form of erythema multiforme, regarded by several 
authors as a distinct affection, in which the characteristic lesions are 
of the dimensions of semi-globular pea- to fist-sized tumors, pale red 
to livid blue in color, tender upon pressure, and exhibiting in their 
involution the variegations of hue already described. They occur 
chiefly upon the legs and dorsum of the feet, but also more rarely upon 
the trunk and the face. Though occasionally becoming so soft to the 
touch that fluctuation may seem to be present, they never terminate by 
suppuration. 

Unna lays stress in the distinction between this disease and erythema 
multiforme upon the fact that the lesions of erythema nodosum never 
widen concentrically, never produce bullae, and never exhibit annular 
vesicles. 

The nodose lesions occur most often in youth, in girls more often 
than in boys, with acute or subacute symptoms frequently with rheu- 
matoid pains and febrile temperatures. The oval or roundish, eryth- 
ematous or empurpled nodes, varying in size from that of a small nut 
to that of a pigeon's egg, are most often seen on the lower limbs, 
though they appear also on the thighs, the buttocks, and the fore- 
arms. They are usually tender on pressure, and often painful. They 
may disappear in a fortnight, but occasionally observe a stadium of 
six weeks' duration, forming and disappearing in crops. The petechial 
appearance of the spots where they have existed is that of the charac- 
teristic u black-and-blue " mark. By some authors this disease is 
recorded as associated with tuberculosis, an observation probably due 
to the fact that it appears so often among the poorly nourished and 
ill-housed. It unquestionably occurs most frequently in the spring 
and autumn, and is not infrequently associated with arthritis or a rheu- 
matic diathesis. Other causes cited are : malarial chills, temperature- 
changes, endocarditis, urethral irritation (blennorrhagic, instrumental), 
medicamentous ingesta, alcoholic excesses, and dentition (?). 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For descriptions of these the reader 
is referred to the sections devoted to Dermatitis Medicamentosa and 
Dermatitis Venenata. Quinine, arsenic, belladonna, chloral, salicylic 
acid, iodine and bromine compounds, and other substances are often 
responsible for these symptoms. 

The name " multiforme," given to this disease by Hebra, is justified 
by the singular diversity of lesions which it displays. These lesions 
are remarkable, not merely for their variety, but also for their occur- 
rence in such variety both simultaneously and successively, and for 
their rapid change from one type to another. 

The subjective symptoms, save in the urticarial form of the dis- 



206 INFLAMMATIONS. 

ease, are usually of a trifling character. The slight sense of heat and 
burning awakened by the lesions is altogether out of proportion to 
the extent of their development. 

The symptoms, however, indicative of a general disturbance of the 
system may be of a marked character. General malaise, fever, inap- 
petence, pharyngeal inflammation, chills, severe gastro-intestinal dis- 
order, rheumatoid involvement of the articulations, and even organic 
changes in the heart (valves, endocardium, and pericardium), lungs, 
and kidneys have all been noted as coincident or as causative phe- 
nomena. In many of these cases it is clear that the exanthem belongs 
to the list of symptomatic erythemata, and that it is of insignificance 
in comparison with the grave general condition. It may thus be the 
precursor of typhoid fever, malaria, or severe articular rheumatism, or 
may become even an abortive expression of these disorders. With 
these exceptions, however, the prognosis is in general favorable, as the 
disease may terminate in a few days, and rarely exceeds a month in 
duration. 

Occasionally the mucous membranes are affected to a disagreeable or 
even painful extent. Thus, a sudden tumefaction of the uvula may 
supervene upon the cutaneous symptoms, in cases sufficient to impede 
respiration ; or the lining membrane of the larynx may be involved, 
and the resulting aphonia in various degrees persist for two or three 
days. 

Etiology. — The affection is commonest in the spring and autumn ; 
it occurs in the young or in the early periods of adult life ; the papular 
and tubercular forms are more common in men, and the nodose forms 
in women ; many patients are affected with rheumatism. In three valu- 
able contributions to the study of the visceral complications of the 
erythema group Osier l has shown that the cutaneous symptoms may 
be merely surface-expressions of a visceral disorder ; and indeed that 
the skin-symptoms may wholly be absent when the disease is in prog- 
ress. In the twenty-nine cases studied by him there were three sets of 
symptoms: (a) polymorphous skin-lesions, including acute circum- 
scribed oedema, urticaria, purpura, and ordinary forms of erythema 
multiforme ; (b) visceral lesions, including (1) gastro-intestinal crises 
in which severe colic, with or Avithout vomiting, diarrhoea, or bloody 
stools, was frequent, (2) hsematuria and nephritis, (3) hemorrhages from 
mucous surfaces, (4) cerebral symptoms, (5) pulmonary complications ; 
and (c) infiltration of synovial sheaths and periarticular tissues, and 
arthritis. In some of his cases a given visceral lesion had been accom- 
panied at different times in the same individual by each of the types 
of cutaneous lesions. 

The etiology of erthema multiforme includes a list of varying and 
Avidely differing causes. Among the concurrent disorders may be 
named : cardiac affections, diphtheria, Bright' s disease, 2 toxaemias, and 
neurotic disturbances. Severe manifestations of the disease have been 
observed in a young woman with extensive ulceration of the cervix 

1 Amer. Jour. Med. Sci., 1895, n. s., ex., p. 629 ; Brit. Jour. Derm., July, 1900, xii., 
p. 227, and Amer. Jour. Med. Sci., 1904, exxvii., p. 1, with general survey of subject. 

2 Of. Vredensky, Vratch, 1901 (abstr. in Brit. Jour. Derm., 1902, xiv., p. 360). 



ERYTHEMA MULTIFORME. 207 

uteri. Tilbury Fox noted a frequency of symptoms in young ser- 
vants brought to town from the country. It is not rare in young 
female immigrants who have recently made a " steerage " passage to 
America. Mackenzie 1 has called attention to the relationship of ery- 
thema multiforme to rheumatism and to purpura rheumatica. 

Galloway 2 calls special attention to the influence of malaria as a 
cause of erythema. 

There can be little doubt that erythema multiforme, arthritic pur- 
pura, urticaria, and acute circumscribed oederoa are closely related. 
The reasons for such belief, as stated by Osier, are : the similarity 
of conditions under which these disorders occur, the identity of the 
visceral manifestations, and the substitution of these affections for each 
other in one and the same patient at different times. The cutaneous 
changes are undoubtedly due to the presence of toxins, which may not 
always be the same at different times eyen in the same individual. 
Moreover, the character of the toxin in a given case evidently is less 
effective in determining the exact nature of the cutaneous changes 
than is the individual idiosyncrasy or the temporary condition of 
the tissues. 

Pathology. — Erythema multiforme is essentially a hyperemia of 
the integument that, under certain obscure influences, advances more 
or less rapidly to the stage of a mild grade of inflammation with conse- 
quent exudation. If, with Landois and Lewis, it be accepted that 
the process is the result of vasomotor nerve influence, it cannot be 
determined whether these nerves are irritated at their points of origin 
or of distribution. In the case of erythema nodosum Hebra advanced 
the hypothesis that the morbid process is essentially an inflammation 
of the lymphatic vessels. In some cases it is evident that there is 
extravasation of blood from the vessels into the skin of the affected 
part. 

Leloir 3 discovered in the papules, tubercles, and bulla? of erythema 
multiforme only the phenomena of hyperemia and exudation limited 
to the corium and subcutaneous tissue ; and Villemin 4 simply confirms 
these facts. Singer 5 has shown that the skin-lesions in erythema multi- 
forme are for the most part evidences of staphylococci and strepto- 
cocci in the blood. Crocker, examining a patch of erythema tuber- 
culatum, recognized merely a cell-effusion in the upper portion of the 
corium extending sparsely below, and then chiefly along the ducts and 
follicles. There was slight rete-proliferation. Unna recognizes both 
in erythema multiforme and erythema nodosum : vascular dilatation, 
cell-proliferation especially around the vessel-walls with cell-emigra- 
tion, and oedema of the cutis. In two cases of the iris-type Pardee 6 
found simply an acute exudative inflammation of the upper part of the 

1 Brit. Jour. Derm., 1896, viii., p. 116. 

2 Ibid., 1903, XT., p. 235 — a review of the causes of the different types of erythema 
and of their relations to svstemic conditions. 

3 Bull, de la Soc. anat., 1884, lix., p. 294. 

4 Gaz. hebdom., 1886, Nos. 22 and 23. 

5 Wien. klin. Wehnsehrift, 1897, p. 38. 

6 Johns Hopkins Hosp. Bull., 1898, ix., p. 165. 



208 INFLAMMATIONS. 

corium. Torok * and Kreibich 2 also find the condition to be a simple 
dermatitis and not an angioneurosis. 

Diagnosis. — Erythema multiforme is always to be carefully distin- 
guished from the traumatism producing bruises, especially upon the 
lower extremities. This point may have an interesting bearing 
upon certain medico-legal questions, especially in the case of young 
children. 

The tendency of the disease here considered to symmetrical arrange- 
ment upon the two sides of the body, the occurrence of lesions evi- 
dently dating from several periods in which successive crops appear, 
and the absence of all history of external injury, will usually suffice to 
establish a diagnosis. Among the precocious affections of the subcu- 
taneous connective tissue in syphilis Mauriac described a lesion re- 
sembling somewhat the symptoms of erythema nodosum; but in such 
cases, and especially in women, mucous patches of the vulva, of the anus, 
or of the mouth, with coincident adenopathy, would point to the real 
nature of the disease. Syphilitic nodes and gummata are distinguished 
from the lesions of the nodose forms of erythema by the pain attending 
the former, their fewness, their overlying integument untinted save 
when actually softening and approaching disintegration, their obvi- 
ously subcutaneous site, and the usual concomitant symptoms of late 
lues. 

The chief points by which a diagnosis of the erythemata in general 
is established are : the recognition of the vivid coloring of most of the 
lesions ; their oedematous character ; their symmetry as a rule ; the pig- 
mentation following those situated on the lower limbs ; their frequent 
association with rheumatism or rheumatoid pains, febrile phenomena, 
malaise, or other constitutional disturbances. The wheals of urticaria 
are smaller, more whitish centrally, more closely packed together, less 
symmetrical, rarely grouped, and, as a rule, decidedly more acute than 
those of erythema. Cases difficult to assign to either disease are com- 
mon, and an error in either direction is not serious. Eubella (German 
measles) is to be distinguished by its adenopathy, its pharyngeal symp- 
toms, and its flattish spots. In eczema erythematosum there is less 
definition of each patch, and the redness is commonly diffuse ; papular 
forms of eczema are usually commingled with other readily distin- 
guished symptoms of that disease. 

Potassium iodide and a few other drugs administered internally are 
capable of producing almost every one of the lesions described above. 
In the erythemata for which iodine and bromine salts have been admin- 
istered, with the production of skin-symptoms, the confusion produced 
becomes a fruitful source of error. 

Treatment. — As in the majority of instances the disease under con- 
sideration progresses naturally to a favorable termination within the 
course of a few weeks, the duty of the physician is usually limited to the 
question of diagnosis and to a study of the etiology in each case, with 
the purpose of preventing future attacks. He should remember that 

1 Archiv, 1900, liii., p. 243 (with review and criticism of various theories advanced 
regarding the nature of the disease). 

2 Ibid., 1901, lviii., p. 125. 



ACRODYNIA. 209 

the larger lesions seen in erythema nodosum never suppurate, and thus 
should not be tempted to open them with a lancet. Local treatment is 
often unnecessary. For the relief of the slight burning or itching present 
in some cases a dusting-powder, sedative or antipruritic lotion, or other 
protective dressings, such as are recommended for the treatment of 
acute eczema, may be employed. Bullae and vesicles should be evacu- 
ated and protected with a simple antiseptic dressing. Internally such 
medication should be employed as is indicated by the general condition 
of the patient. Iron, quinine, the salicylates, salol, strychnine, and 
dilute hydrochloric acid will be found beneficial in many cases. Con- 
stipation and indigestion are to be corrected by appropriate measures. 
A full dose of calomel or blue mass, followed by a saline laxative, is 
demanded in many cases to aid in the elimination of intestinal toxins. 
When the disorder accompanies rheumatic or other systemic disease 
internal treatment is to be directed to the general condition present. 
When the erythema produces extensive oedema of the uvula incisions 
may be requisite to prevent dyspnoea and dysphagia. 

Prognosis. — It will be gathered from what has preceded that the 
prognosis is usually favorable, but necessarily varies with the constitu- 
tional disease of which the erythema may be a mere symptom. The 
malady may relapse in susceptible individuals at those periods of the 
year when it is observed most frequently. 



ACRODYNIA. 1 

(Dexgue Fevee, Eheumatismus Febkilis Exaxthematosus, 
Rhetjm atismus Febrilis Epidemicus, Arthkodyxia, Boquet, 
bou-bou, kxockelkoorks, plaxtaria.) 

Acrodynia is an acute infectious disease accompanied by articular 
and muscular pains and by the exhibition of eruptive symptoms, the 
affection occurring for the most part along the coast-line of warm 
countries, more particularly in the southern parts of Europe and 
America, including the West Indies, in Asia and Africa, and also in 
the Philippine and Sandwich Islands. 

Symptoms. — There is commonly a prodromal period lasting from 
a few hours to two days, characterized by twinges in the joints, by 
gastro-intestinal and nervous symptoms, by general depression, and by 
a feeling of malaise. 

Often, however, the disease begins with suddenly occurring chills 
followed by febrile temperatures (103°-106° F.), remittent rather than 
intermittent in type, by headache, accelerated pulse, and characteristic 
pains in the larger and smaller articulations, especially in the knee- 
joints, the muscles at the same time being often exquisitely tender and 

1 Bibliography: Manson, Tropical Diseases, London, 1900, p. 195 ; Scheube, Falcke, 
and Cantlie, Diseases of Warm Countries, Philadelphia, 1903, p. 38 ; Brun, Bull, de 
l'Acad. de Med., 1893, xxx., p. 227; Davidson, Hvgiene and Diseases of Warm Coun- 
tries, 1893, p. 323 ; von Diihring, Monatshefte, 1890, x., pp. 16 and 128 ; Forrest, Amer. 
Jour. Med. Sci., 1891, lxxxi., p. 329 ; Hirsch, Handbuch der. hist. Geog. Pathologie, 
3881 ; Leichtenstein, Xothnagel's Specielle Pathologie u. Therapie, Wien, 1896, p. 197. 
14 



210 INFLAMMA TIONS. 

the seat of pain. The popular name, " dandy fever " (dengue), is sup- 
posed to be derived from the oddity in the gait of sufferers from the 
disorder. 

The Initial Rashes of the disease are of the order of the toxic 
erythemas (maculations of the surface due to vasomotor disturbance) 
most conspicuous in the facial region and lasting only for from one to 
five or six hours. At the same time the eyelids become puffy ; and 
there may be coincident lachrymation, photophobia, secretion from the 
nares blocking at times the external orifices, injection of the con- 
junctival and pharyngeal membranes, and dysphagia due to tume- 
faction of the tonsils. 

With these symptoms there may be severe or slight salivation, a 
coated tongue, jaundice, albuminuria, insomnia, and other signs of 
grave systemic disturbance. 

Defervescence commonly occurs about the fourth day, the symp- 
toms then rapidly losing their severity and distinctive features. 

Terminal Ex anthem — the so-called secondary eruption of the 
malady — though in some cases absent, occurs usually between the third 
and sixth day of the disease, with or without further pyrexic symp- 
toms, with evolution of macules, though there may be vesicles, blebs, 
pustules, or wheals, chiefly over the face, hands, forearms, thighs, and 
chest, though it may be both symmetrical and universal. The com- 
monest form of the exanthem is that in which isolated, slightly raised, 
dull-reddish, pea-sized spots appear which may coalesce and later 
become purplish-brown in hue. Man son states that where there is 
marked coalescence, the islands of sound skin produce, at first sight, the 
impression that they constitute the eruption, a species of pallid exan- 
them on a scarlet ground. The lesions have been described as resemb- 
ling those occurring in measles, scarlatina, urticaria, roseola, lichen, 
etc. The palms and soles are oftener of a brilliantly vivid hue. The 
subjective sensations awakened are pricking and burning. Simulta- 
neously, there is adenopathy of the cervical, axillary, and inguinal 
glands usually temporary in duration. The exanthem may endure for 
a few hours only or for several days, and may recur after complete or 
partial disappearance. 

Desquamation, slight and furfuraceous, occasionally with shedding 
of large flakes, may follow during from two to three weeks and be 
accompanied by severe pruritus. 

The subsequent course of the disease is toward a convalescence 
often interrupted by severe recurrences of pain in one or more joints 
or muscles. Beside the adenopathy named above, there may be pro- 
found physical prostration, furunculosis, orchitis, albuminuria, and 
cardiac complications. 

Etiology. — Dengue belongs to the category of the exanthemata in 
general, the essential factors in which have been recognized so rarely. 
" Mobile granules " have been found by Hunt in blood freshly removed 
from patients : also in bouillon infected with their breath. The dis- 
ease is contagious ; is transmitted most often to individuals living on 
the coast-lines by the medium of ships and travellers ; is relatively 
rapid in its spread ; and is one communicable to attendants and physi- 



PYROPLASMOSIS HOMINIS. 211 

cians. The virus of the disease is believed to be capable of transmis- 
sion through the medium of the soil and the clothing. It is favored 
by high atmospheric temperatures, but conditions of sex, race, age, 
and occupation seem to be of no etiological importance. 

Pathology. — In four post-mortem examinations of the dead made 
by Nogu6, there were lesions of the lungs and of the brain (meningitis 
with adhesions, and sero-purulent infiltration of the pia mater). 

Diagnosis. — The affections with which the disease is most liable to 
be confounded are the exanthemata. The characteristic muscular and 
articular pains of dengue, occurring both during and after the attack, 
with the special peculiarities of the exanthem, must be relied upon for 
a recognition of the disease. 

Treatment. — As the affection is one which accomplishes a cycle of 
evolution and involution, the treatment is that indicated by the general 
condition of each patient, including a light diet, rest, the antipyretics, 
and opiates when needed for relief of the pain. The eruptive symp- 
toms are to be treated, if at all, by emollient baths, and soothing dusting 
powders. 

The Prognosis is in general favorable, the very young and old 
offering, the most unfavorable chances of recovery. 



PYROPLASMOSIS HOMINIS. 

(Spotted Fever, Tick Fever, Rocky Mountain Fever, 
Black Fever, Blue Disease.) 

Under this title Maxey first in 1899, and later Wilson and 
Chowning 1 have described an eruptive fever occurring in the Bitter 
Root valley of Montana, and attacking the white population chiefly. 
Two hundred cases have been observed, many with fatal issue. 

Shortly before the onset of symptoms the patient has been bitten 
by ticks, the resulting lesions becoming tender and the seat of radi- 
ating pains. Chill, malaise, and fever rapidly follow, with an eruption 
developing between the second and seventh days, at first appearing 
over the wrists, ankles, and back, but later becoming generalized. 
The lesions are rose-tinted macules, 1 to 5 mm. in diameter, circular in 
outline, occasionally involving the mucous membranes. At first they 
disappear on pressure ; later they become purplish or bluish with a 
confluent marbling of the skin, most conspicuous over dependent 
portions of the body. Ordinarily there is an accompanying jaundice. 
Desquamation sets in during the third week, with disappearance of the 
exanthem in favorable cases ; in others, gangrene may affect special 
parts, such as the digits, scrotum, ears, etc. Cases are reported where 
no eruptive symptoms appear : these are of doubtful significance. 
The mortality is from 70 to 80 per cent, in the cases in which eruptive 
features are recognized. 

Etiology. — Persons of all ages and both sexes are attacked, chiefly 
during the months from March to July : there is no record of direct 
1 Jour. Infect. Dis. 1904, i., p. 31. 



212 INFLAMMATIONS. 

transference of the malady from one subject to another : there are no 
symptoms pointing to visceral infection. All subjects of the disease 
examined by Wilson and Chowning, were tick-bitten. 

Pathology. — No bacteria of etiological significance were obtained. 
In freshly drawn blood red cells were discovered infected with pyro- 
plasma hominis, usually a bigeminate form and ovoidal ; 1 mm. in thick- 
ness and 1 to 2 in length. These existed both within and between the 
erythrocytes. The disease was reproduced in the lower animals from 
pure cultures of the hsematozoa. The host in these cases was recog- 
nized as Spermophilus Columbianus, the blood of which in the infected 
areas of the valley was discovered to contain parasites indistinguishable 
from the same organisms recognized in the blood of patients. 

The Treatment suggested by the authors is the administration of 
quinine both by the mouth and subcutaneously. 

The Prognosis is for the most part exceedingly unfavorable. 



ERYTHEMA ELEVATUM DIUTINUM. 

Under this title, proposed by Campbell Williams and Crocker, 1 the 
latter describes a rare disorder characterized in most instances by the 
appearance of pea- to bean-sized, firm, painless nodules which are pink 
at first but gradually assume a purplish hue. At first distinct, the 
nodules tend to coalesce to form irregular, lobed infiltrations, or flat, 
raised plaques, or, in exceptional cases, distinct nodular tumors. The 
lesions have been encountered chiefly on the extensor surfaces of the 
limbs and joints, but have been seen also on the palms, soles, buttocks, 
and ears. In most of the cases reported the lesions persisted for years, 
though in two cases they gradually underwent involution. The pa- 
tients have been children or young adults, and all but one were females. 
They all showed either a personal or family tendency to gout or 
rheumatism. 

Histological examination of Williams and Crocker's case showed 
lesions of the nature of fibromata of the corium but of inflammatory 
origin. 

Stelwagon 2 classes with these cases three observed by himself hav- 
ing some similar features, though his patients were all past the age of 
forty, and in all cases the lesions developed more rapidly and underwent 
complete involution within four months. 

Treatment is unsatisfactory. 

1 Diseases of the Skin, p. 142. 

2 Diseases of the Skin, p. 159. 



PELLAGRA. 213 

PELLAGRA. 1 

(Lat. pellis, the skin ; ceger, diseased.) 

(Lombardy Erysipelas, Lombardy Leprosy, Kisipola Lom- 
barda, Lepra Italica, La Rosa, Mal Roxo.) 

This is a chronic constitutional disorder prevailing as an epidemic 
in various parts of Europe, Asia, and North America, characterized by 
gastro-intestinal, nervous and other morbid symptoms, being also ac- 
companied by an erythematous exanthem. The disease is recognized 
chiefly in Italy (Lombardy, Venice, Emetta), but occurs also in parts 
of Spain, France, Portugal, lower Egypt, and Mexico (Yucatan, Cam- 
peche). 

Symptoms. — The symptoms of pellagra differ to a marked degree 
in different subjects of the disease and in the different countries in 
which it is endemic. The course of the disease is essentially chronic, 
and is characterized by remissions and aggravations in recurrent 
attacks. There is commonly a prodromic stage, of longer or shorter 
duration, which may extend over several winters preceding the 
spring in which most often marked symptoms are declared. The sub- 
jects of the affection then experience languor, suffer from vague pains 
in various parts of the body, and are disinclined to labor by reason of 
bodily weakness. These recurrent evidences of ill health are followed 
by marked anorexia, thirst (often intolerable), or inappetence for both 
food and drink, abdominal pains, eructation of gas, and loose stools, 
often with bloody alvine evacuations. These signs of disorder are 
accompanied generally by nervous symptoms, including pains and 
tenderness of the head, vertigo, dizziness, marked asthenia, mental 
dejection and hebetude, with increase of the tendon-reflexes and inco- 
ordination of movements, more particularly of the lower extremities. 

The cutaneous symptoms may be a marked feature of the disorder 
or be wholly lacking. The skin, especially of exposed regions, such as 
the face, neck, upper chest, backs of the hands, lower third of the 
forearms, dorsum of the feet, and in the case of persons who are almost 
entirely nude during the day, such as the Fellahs of Egypt, the entire 
body surface becomes involved. The surface is then reddened, tumid 
(toxic erythema), and either smooth or disclosing the usual signs of 
dermatitis (vesicles, blebs, pustules, crusts, etc.). As the subacute 
attack subsides there follow desquamation, pigmentation, harshness 
of the surface, and the condition commonly following repeated attacks 

1 Bibliography : Gemma, Ann. univ. di med., 1871, p. 564; Winternitz, Vierteljahr. 
1876, iii., p. 151; Paltauf u. Heider, Der Bacillus Maidis (Caboni) und seine Bezie- 
hungen zur Pellagra, Vienna, 1889 ; Raymond, Annales, 1889, x., p. 627 ; Pellizzi, u. 
Tivelli, Centralbl. f. Bakt. u. Parasit.,*1894, xvi., p. 186; Carravoli, Giorn. della r. 
Soc. ital. d'igiene, 1896, Nos. 7-9 ; Lombroso, Die Lehre von der Pellagra, Berlin, 1898 ; 
Sandwith, Brit. Jour. Derm., 1898, x., p. 395, and Jour. Trop. Med., 1898, i., p. 63; 
Babes and Sion, "Pellagra," Nothnagel's Spec. Path. u. Therapie, xxiv., Pt. ii., fasc. 
iii., Vienna, 1901 : Scheube, Falcke and Cantlie, Diseases of Warm Countries, Philadel- 
phia, 1903, p. 311'; Ceni, Centralbl. f. Allg. Path. u. path. Anat, 1903, xiv. p. 465; 
Galli, Med. Wchnschrft, 1901, Nos. 34 u. 35 (abstr. Archiv, 1903, lxvi., p. 263) ; Verotti. 
Giorn. intemat. d. Sc. Med., Napoli, 1903, xxv., p. 273; Stefanowitz, Wien. klin. 
Wchnschrft,, 1903, xvi., p. 1089. 



214 INFLAMMATIONS. 

of dermatitis, the skin becoming shrunken, wrinkled, atrophic, and 
xerodermatous. 

The other pronounced symptoms of pellagra are marked sensori- 
motor phenomena (muscular weakness, at times amounting to paraly- 
sis ; tremor or tetanic contractions ; parsesthesic diplopia, hemeralopia, 
melancholia, and imbecility). At times dementia follows. The coordi- 
nate symptoms may be fever, in varying gradations of temperature, 
and marked circulatory changes. 

In the final stages of the disease cachexia is induced and the 
patient falls into a condition of marasmus (typhus pellagrosus) with 
the usual signs of extreme weakness (involuntary defecation and urina- 
tion, sordes on the teeth, intercurrent pneumonia, or other fatal com- 
plication). 

Etiology. — Pellagra is believed to be due to the consumption for 
long periods of time of damaged maize, this being a staple article of 
food in most of the countries where the disease is endemic. The eat- 
ing of grain harvested before it is fully ripened, particularly in regions 
where famine has existed, the harvests are poor, and the lower class 
of rural population live in insalubrious conditions — is the chief factor 
in the production of the malady. 

Persons of both sexes and all ages are liable to contract the dis- 
ease ; heredity is supposed to exert an influence, especially when the 
nervous symptoms of the malady are predominant. The sporadic 
cases occurring where there has been no suspicion of the ingestion 
of improperly prepared food, are believed to represent a " pseudo- 
pellagra " having a wholly different etiological history. 

Pathology. — It is not yet determined whether the germ of the dis- 
ease is developed in the unsound maize or in the structures of the 
body. Most of the fungi discovered in the grain (sporisorium mai'dis ; 
coecoma ma'idis or ustilago ; sclerotium ; bacillus of Carraroli) have 
been shown to be harmless. Post-mortem there have been recognized ; 
fatty and atrophic cardiac changes ; brown atrophy and fatty degenera- 
tion of the liver ; cirrhosis of the kidney ; intestinal ulceration ; hyper- 
semia, anaemia, oedema of the brain, cord, and meninges, symmetrical 
sclerosis of the cord ; and, in typhoid cases, acute myelitis. The most 
constant and pronounced of these morbid conditions are symmetrical 
sclerosis of the posterior columns of the cord, corresponding with the 
track of the lateral pyramidal fasciculus. 

Diagnosis. — As the cutaneous lesions are at times wholly absent 
the recognition of the disease depends for the most part on the other 
morbid symptoms presented. The region in which an endemic influ- 
ence is exerted is of importance in determining the character of any 
case. Sherwell, of New York, reports instances of the disease occur- 
ring in sailors coming to New York from Italian ports, who have been 
eating polenta prepared by themselves. In these cases the eruptive 
symptoms were present. 

The Treatment is by prophylaxis, especially in the matter of storing 
of grain and in the preparation of spirits distilled from unsound maize. 
There should be improvement of the hygienic and climatic conditions 
of the patient ; quinine and tonics in cases of debility ; proper manage- 



URTICARIA. 215 

merit of nervous and gastric troubles ; and, when practicable, a gener- 
ous dietary. Lombroso recommends arsenic internally, and the tincture 
of cocculus (gtt. v-x) in the treatment of giddiness. The spinal 
symptoms are managed best by massage, electricity, and alcoholic or 
salt embrocations. 

The Prognosis is favorable in some cases, which may be so mild as 
to be scarcely noticeable ; in others it is grave ; and in districts where 
the disease prevails extensively the mortality may be formidable. 

URTICARIA. 

(Lat. urtica, the nettle.) 

(Hives, Nettle-rash. Fr., Urticaire; Ger., Nesselstjcht, 
Nesselausschlag.) 

Urticaria is an exudative affection of the skin in which appear 
ephemeral whitish or rosy tinted Avheals, accompanied by burning, 
stinging, pricking, tingling, or itching sensations. 

Symptoms. — This disorder may be ushered in by constitutional 
symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
phenomena lasting for a few hours or even a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the skin-surface, that 
frequently disappear with equal rapidity, leaving no traces of their 
existence save a slight and transitory hyperemia of the affected spot. 
The lesions may be as small as a finger-nail or a coffee-bean, and usually 
are of this size; but in rare instances " giant "-wheals are seen — large 
tomato-sized projections or flat elevations of broad areas of the integu- 
ment, that cover the greater part of the belly or buttock. In color 
the lesions are rosy red or whitish, and are usually surrounded by 
a hypersemic areola. They may be isolated and few, or be numerous 
and closely packed together ; they may even coalesce, so that individual 
wheals are scarcely recognizable. They are usually firm and semisolid 
to the touch. Rarely, the horny layer of the skin is raised in fluid- 
containing lesions by the sudden effusion of serum beneath. In contour 
they are roundish or oval-shaped, but a variety of curious outlines may 
result from the irregularity of their development. Concentric circles, 
lines, bands, and even figures are in this way produced. The finger- 
nail drawn across the unaffected portions of the skin of a patient with 
urticaria will often produce a linear wheal (" urticarial autogram") of 
extent corresponding with the line of irritation (dermographism). In 
this way the so-called " medium " with a sensitive skin exhibits written 
characters upon the surface of his body. 

The subjective sensations induced by these lesions are distressing 
in varying degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensationsj is thus engendered. The efforts of the 
patient to secure relief by scratching not only serve still further to 
develop the eruption, but also to irritate, tear, and otherwise wound 
the lesions already in full evolution. In this way serous effusions are 



2 1 6 INFLA MM A TIONS. 

produced at the summits of the Avheals ; and in this way, also, lesions 
really transitory in their course may be changed to more persistent, 
deeply colored, flat, lenticular papules. Where the skin is delicate 
and thin, as is that of the lids and prepuce, considerable oedema may 
result. 

All parts of the body may become affected, irrespective of age and 
sex, though children are particularly liable to the disease. There are 
few very young children with skins unwashed for an entire month 

Fig. 38. 




Autographism in urticaria. 



who will not exhibit urticarial symptoms if there be an added irrita- 
tion of the surface. The disease occasionally involves the mucous 
membrane of the mouth, pharynx, and larynx. 

The lesions numerically may be few or be so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they often recur from apparently insignificant causes, or even 
become chronic. In many cases trivial the disease may become so 
aggravated as to make the largest demands upon the skill of the 
physician. 

The rapidity of appearance and disappearance of the lesions visible 
upon the skin is a characteristic feature of the disease. In some 
instances but a few moments are required after the operation of an 
efficient cause to develop a large number of closely packed wheals. 
Even while they are under inspection it can be noted that there is a 
change in individual lesions, some fading or completely disappearing, 
while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus, Urticaria annularis occurs in rings ; U. figurata, in gyrations 
from union of several lesions or patches of lesions ; U. vesiculosa and 
U. bullosa, where there is a vesicular or bullous development at the 
summit of the lesion ; U. papulosa (or Lichen urticatus), where there 
is a combination of the features of the wheal and the papule, the 
lesions being naturally grape-seed- to coffee-bean-sized, and covered 
with blood-crusts where their apices have been torn in scratching ; 
U. tuberosa, where " giant ''-wheals occur, some attaining the size of 
a hen's egg ; U. hemorrhagica (Purpura urticata), where the urticarial 
element is developed in a lesion produced by cutaneous hemorrhage ; 



URTICARIA. 217 

and U. evanida, or perstans, where there is, respectively, a rapid or a 
slow process of involution in the characteristic symptoms. 

Baker x reported a case of Urticaria Tuberosa characterized by 
the presence in various parts of the body of persistent yellowish-red 
tubercles, which proceeded to ulceration. The parts most affected were 
the knuckles, the elbows, and the ear. These tubercles are said to 
have begun in a manner similar to that which characterizes the onset 
of evanescent urticarial wheals and tubercles. A somewhat similar 
case was observed by McCall Anderson. 2 

Urticaria, like erythema, may be either idiopathic or symptomatic ; 
and in each form the urticarial conditions may underlie or be superim- 
posed upon almost every elementary lesion noted in the integument. 
The wheal may complicate (or be complicated by) the macule, papule, 
tubercle, vesicle, bulla, and pustule. It may spring from an excoria- 
tion or may result in a fissure. It is common in traumatisms, and is a 
prominent symptom in the skin bitten by insects, reptiles, or domestic 
animals. 

Etiology. — Idiopathic urticaria always results from the action of 
external irritants, prominent among which are the bites or stings of 
mosquitoes, lice, fleas, bedbugs, gnats, wasps, caterpillars, and bees. 
The irritant action of the nettle ( Urtica urens and U. dioica) has given 
the malady its name. Contact with certain species of the jelly-fish is 
also effective. The wounds thus inflicted usually give rise to a stinging 
or a burning sensation, by which the patient is excited to rub or scratch 
the part. A wheal is rapidly formed at the site of the injury, and the 
irritation set up is conveyed to other parts of the skin in the vicinity, 
so that, especially in children, a single traumatism by an insect may 
excite an urticaria covering a much larger area. Many medicaments 
operate similarly, and it should be added that all the external agencies 
which are capable of irritating the skin, though applied without toxic 
effect to the mass of men, may produce urticaria in individuals predis- 
posed to the disease, or having a peculiar intolerance for a particular 
substance. Thus, a common flaxseed poultice when made to cover but 
a small portion of the body has produced violent symptoms of urticaria. 
Climatic influences, more particularly those in which the surface of the 
body is exposed to cold air, are efficient in the production of urti- 
caria, as also of bronchial asthma, with the symptoms of which the 
disease under consideration, in the case of adults, may often coexist or 
alternate. Mechanical violence, the application of leeches to the skin- 
surface, and surgical traumatisms may also act as exciting causes. 

Symptomatic urticaria is chiefly of the variety named by authors 
ab ingestis, since it most frequently results from medicinal or from 
dietary articles taken into the stomach. Of the latter class may be 
named eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery, 
crabs, lobsters, clams, caviar (and several species of fish-roe), oysters, 
and fish generally, strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, raspberries, canned 
("tinned") fruits, meats, vegetables, oatmeal, pease, beans, onions, 

1 Lancet, August, 1881, i., p. 153. 

2 Brit. Med. Jour., 1883, L, p. 1103. 



218 INFLAMMATIONS. 

garlic, " corn," pickles, sauces, honey, mushrooms, pastry, salads, and 
spinach. Vinegar, champagne, beer, and alcoholic beverages in gen- 
eral are capable of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may be 
named the balsams, the turpentines, quinine, glycerin, chloral, valerian, 
arsenic, hyoscyamus, cinchonidine, salicylic acid and the salicylates, 
senna, santonin, and opium and its alkaloids. 

In the case of children and infants a severe urticarial efflorescence 
may be provoked by worms, or by any undigested morsel of food, 
or indigestible material of any sort that may have been passed into 
the stomach. Thus, a bit of orange-peel or a fragment of potato- 
paring or the skins of grapes may be discovered to lie at the root 
of the trouble. In the case of adults, also, who have experienced 
repeated attacks of urticaria, and suffer from sensitiveness of the gastro- 
intestinal tract, any food not easily digested by a given individual may 
induce in him a return of the disagreeable symptoms. 

This undue sensitiveness to the effect of ingesta or of external irri- 
tants is often an idiosyncrasy peculiar to the individual either on special 
occasions or at all times, and, given this susceptibility, the effect is 
often great with a relatively insignificant etiological factor. Thus, a 
teaspoonful of beer, one grain of quinine, the smallest fragment of 
cheese, or but a single strawberry, may not only induce an urticarial 
rash of such extent as to cover the greater part of the surface of the 
body, but will also do the same on every occasion when the articles 
named are swallowed in the quantities given. The fact that a small 
quantity of the article ingested can produce urticaria is important, 
because it emphasizes the general characteristics of the medicamentous 
eruptions. The a priori reasoning, that the greater the quantity of 
the toxic agent applied or swallowed, the graver the effect, may lead 
to gross errors. It should be remembered, in seeking the explanation 
for an urticarial rash, that the smallest amount of apparently innocent 
substances may be responsible for the largest annoyance. In excep- 
tional cases the mere odors of iodoform, linseed, liquorice, certain 
plants, etc., have been sufficient to cause an attack of urticaria. 

Other causes of urticaria may be cited, such as moral emotions (fear, 
shame, anger) ; pulmonary diseases, especially asthma ; gastro-intestinal 
disorders, in which ingesta play no part ; intestinal parasites ; malaria ; 
the exanthematous fevers, particularly in their prodromal stages ; dis- 
orders of the uterus, the kidneys, and the nervous centres ; pregnancy, 
dentition, and the irregularities attending the menopause ; and, lastly, 
the following special diseases : pemphigus, prurigo (of Hebra), rheu- 
matism, and purpura. 

The close affinity of urticaria with acute circumscribed oedema, pur- 
pura, and erythema multiforme is discussed with the last-named disease. 

Pathology. — Urticaria usually is classed as a vasomotor neurosis. 
The wheal is a sharply circumscribed cedema, and is produced appar- 
ently by an interchange of play between blood-vessels, muscles, nerves, 
and tissue, under the operation of a principle which the French term 
choc en retour. There is, first, under the influence of the vaso- 
motor nerves, a clonic spasm of the arterioles in a limited area of the 



URTICARIA. 219 

derma, by which is produced an acute oedema with some serous exu- 
date. The rapidity with which this clonus occurs is greater than that 
with which the tissues of the vicinage can accommodate themselves to 
it, either by imbibition or more diffuse tumefaction, and there results a 
counterpressure upon the affected capillaries, by which their lumen is 
still further restricted. As the wheal is not a purely fluid-containing 
nor yet an entirely solid lesion, but is semifluid in consistency, the 
mechanical pressure is greatest at its centre and least at its periphery. 
Thus are explained the white and relatively bloodless appearance of the 
centre of certain wheals, and their rosy or reddened outer border. 
The explanation is strengthened by the fact that generally the most 
acute lesions, those springing into view most rapidly, are chiefly char- 
acterized by this whitened centre, while those more indolent or even 
chronic in their career, having been less subject to the interplay of the 
forces described above, permit of more general vascular injection, and 
have a light-crimson or even at times a dull-red centre. Wheals have 
been excised and microscopically examined by Neumann, Vidal, Pon- 
cet, Unna, and others, with the result of discovering merely evidences 
of dilatation and engorgement of blood- and lymph-vessels. The deep 
vascular net shows the greatest dilatation of the lymph-channels. The 
compression of the blood-capillaries produces the whiteness of the 
acutely developed wheal. According to Poncet, the lymph-vessels 
are also choked with " lymph-clots." Rohe 1 explains the occurrence 
of the wheal by supposing that certain sensitive nerve-fibres of the skin 
possess also a vasomotor function. 

Unna believes the wheal is produced by a spastic contraction of the 
veins. Gilchrist 2 found in the lesions of urticaria factitia of but a 
few minutes' duration an increase in the number of round cells and 
of polymorphonuclear leucocytes, and other evidences of true inflam- 
mation. Torok 3 also finds in urticaria evidence of simple inflammation. 
Torok and Hari, 4 and Phillippson * as a result of numerous experiments 
conclude that urticaria, also the oedema which is present, is due to the 
direct action of an irritant upon the vessels at the point where the cuta- 
neous lesions are produced, and that the disorder is not therefore an angio- 
neurosis. Toxins may reach the vessels from Avithin or from without. 

Diagnosis. — The diagnosis of classical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which con- 
fusion may arise. The chief points to be remembered are : the rapid- 
ity of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action of the animal parasites 
and of insects not parasitic should not be overlooked, and the rash be 
closely examined for the minute wounds inflicted in this way, often 
covered with a minute pin-point- to pinhead-sized dried " blood-scale," 
and usually found in groups of two, three, or more lesions. The 
various forms of erythema papulatum, tuberculatum, and nodosum 
are liable to be mistaken for urticaria ; but this is in many cases inev- 

1 Maryland Med. Jour., 1881, viii., p. 25. 

2 Johns Hopkins Hosp. Bull., 1896, vii., p. 140. 

3 Archiv, 1900, liii., p. 243. i Ibid., 1903, lxv., p. 21. 5 Ibid., p. 387. 



220 INFLAMMATIONS. 

i table, as intermediate forms between the two disorders are with diffi- 
culty assigned to either category. Absence of marked subjective sen- 
sations and persistence of lesions would generally point to an erythema, 
while marked prevalence of these symptoms would probably decide in 
favor of urticarial disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capri- 
ciously selected hours, and who repeatedly and vainly endeavors to 
exhibit the lesions as they appear upon the skin. Being examined on 
various occasions, scarcely a trace of cutaneous disorder is manifest. 
Here the practitioner has actually to decide upon the character of an 
eruption he never sees ; the task is rarely difficult, no other than the 
urticarial eruption behaving in this fashion. Occasionally the physi- 
cian will discover delicate, rosy or deeper stained mottlings of the 
skin-surface where the wheals have been. At times also he will suc- 
ceed, on the flexor aspect of the forearm, or in some situation in which 
the skin is equally delicate, in producing the appearance of one or 
more typical lesions by the aid of his finger-nail in scratching, or by 
rubbing. These cases are more frequently of the chronic or at least 
of the relapsing class, and the victims of the disease may have a char- 
acteristic facies, a worn look from loss of sleep or from mental emo- 
tion. In this class are often those who are mourning the death of 
relatives, the loss of property, or separation from home and friends, 
and those harassed by anxieties. 

The several lesions of erythema are larger than those of urticaria, and 
they do not develop from characteristic wheals ; in erythema multiforme 
the lesions are far more persistent in type and do not provoke the char- 
acteristic subjective sensations of urticaria ; in erysipelas the redness is 
characteristic and the swelling more diffuse. 

Treatment. — Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diagnosis. The patient and his 
friends are alarmed by the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder, they wait with equanimity for the favorable conclusion 
which is always reached. Fortunately, the unusual, severe, and 
relapsing forms rarely begin with acute symptoms. 

Naturally, the first indication to be observed is the removal of the 
cause, and with this, if possible, accomplished, the next is the exclusion 
of all aggravating agencies. The discovery of the cause, at times 
readily effected, is often the most serious problem presented. An 
exhaustive and minute examination of the person and the history of the 
patient, a study of his food, drink, medicine, regime, clothing, sleep- 
ing-apartment, habits, occupations of life, and mental state, are here 
essential. When the disorder is recent, and is an urticaria ab ingestis, 
a brisk emetic or a cathartic may rid the stomach or the bowels of 
offending matters. This done, it should be borne in mind that an 
idiosyncrasy of the patient may at this moment render the skin pecu- 
liarly sensitive to the action of other ingesta, and the diet, for a few 
days certainly, should be prescribed carefully. In many cases the 
alkalies are indicated by an acid condition of the stomach, and then the 



URTICARIA. 221 

preparations of sodium, potassium, or magnesium are useful. Laxa- 
tives, such as rhubarb, magnesia, the cathartic mineral waters, and, in 
the case of children, small doses of castor-oil are frequently indicated 
when there is no suspicion of irritating ingesta. At other times there 
is marked atony of the digestive organs, when the mineral acids, the 
bitters, and the ferruginous tonics may be needed. Again, lactopeptin, 
pepsin, or bismuth subcarbonate or subnitrate may be exhibited with 
advantage for the relief of the indigestion which may be the promi- 
nent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in 1 drachm (4.) doses three times daily in sweet- 
ened water (Da Costa) ; copaiba ; sodium nitrite (J. P. Sawyer) ; strych- 
nine (Guibout) ; sodium arseniate, employed by Blondeau in doses of 
from 3V (0.002) to ^ (0.0013) of a grain ; the fluid extract of ergot 
in J drachm (2.) doses (Morrow) ; atropine sulphate in doses of g- 1 ^ 
(0.001) of a grain (Schwimmer) ; and sodium salicylate in scruple 
(1.33) doses. The latter drug has been praised highly by a number of 
writers. It is often given in 1 grain (0.06) doses every hour. Pilo- 
carpine, or the fluid extract of jaborancli, is known to produce at times 
a powerful effect in relieving surface-congestions of the skin by means 
of the hyperidrosis it occasions, and in proportion to which it is pro- 
duced the drug may become dangerous. 

Schwimmer endorses the following formula for this affection : 



R. Atropine sulph., gr. i ; 

Glycerin, I -- _ . „ 

Aq. dest, j aa 3 ss , I 

Gum. tragacanth, q. s. 

Ft. pil. No. xx. 



01 
M. 



The treatment of symptomatic urticaria should have regard also to 
that disorder of the viscera or of the general system to which the 
cutaneous symptoms may be attributed. Gout, as a not infrequent 
cause of the disease, should not be forgotten in advising treatment. 
The uterine complaint of a woman may require appropriate manage- 
ment, as also the diabetes of a patient with an affection of the kidneys. 
Quinine is indicated, of course, in periodical attacks, but its action in 
exceptional cases as a direct cause of urticaria should not be over- 
looked; the same, to a greater extent, is true of arsenic, potassium 
bromide and iodide, chloral hydrate, and gelsemium. The larger number 
of patients are best treated without the employment of these drugs. 

In the local treatment of urticaria protection of the sensitive skin 
from all sources of external irritation is the chief object. The complete 
covering of an affected region with wadding will often cause a rapid 
disappearance of the symptoms. Individual lesions which are sealed 
with collodion or plaster usually disappear promptly. The zinc-oxide 
adhesive plaster is very serviceable, as it does not irritate the skin. 
The patient's underclothing should be of soft linen, cotton, or silk, and 
to prevent friction with the skin a dusting-powder may be used freely, 
both on the skin and in the meshes of the underwear. Sleep should be 
secured without an excess of bed-covering, and places where the temper- 



222 INFLAMMATIONS. 

ature is for any reason elevated should be carefully avoided by the 
patient, such as proximity to a fireplace or a droplight, heated places of 
amusement, the kitchen, etc. 

Great diversity exists in the methods employed to assuage the 
disagreeable sensations experienced in the skin. This diversity is 
explained by the varying results obtained in different patients after the 
application of the same medicinal agent. Thus, cold and hot water- 
baths, baths medicated by marine salt, aromatic vinegar, alcohol, cologne, 
camphor, the alkalies, and sulphuric ether (compresses dipped in such 
solutions and laid over the part affected), douches, and vapor-baths will, 
any of them, in the case of some individuals, produce a marked allevi- 
ation of symptoms, and in others will be either inoperative or actually 
serve to aggravate the symptoms in the highest degree. Hebra asserts 
that several of the baths named above are useless, while Kaposi recom- 
mends cold lotions medicated with aromatic volatile substances. Fox 
prefers that alcohol, or cologne-water to which benzoic acid has been 
added, be dabbed over the part and permitted to evaporate. Solutions 
of menthol in alcohol and water, 1 part to 500 or 600, operate simi- 
larly. Hillairet and Gaucher employ in a similar way a solution con- 
sisting of one-third of ether and two-thirds of warm water. 

The alkaline bath should contain sodium carbonate, sodium biborate, 
alum, or potassium bicarbonate, either singly or in combination in the 
strength of about 6 ounces (180.) of the salt to 30 gallons of water; 
1 or 2 ounces (30.-60.) of potassium sulphuret may be substituted. 
The water is made demulcent by the addition of starch or of gelatin, 
or by immersing in it a muslin bag containing bran. When it is 
desired to employ the acid bath, l ounce (15.) of either muriatic or nitric 
acid is added to the quantity of water given above. The bath of this 
size may also be medicated with 1 drachm (4.) of corrosive sublimate; 
or this drug may be used as a lotion in the strength of from \ (0.016) 
to \ (0.033) grain to the pint. Carbolic, benzoic, salicylic, boric, dilute 
hydrocyanic, and dilute nitric acids in weak solution are also employed 
with advantage in some cases. 

Other external applications are thymol, ammonium carbonate, potas- 
sium bromide, ether, chloroform, or chloral-camphor in the strength of 
\ to 1 drachm (2.-4.) to the ounce (30.) of ointment. This ointment 
is prepared by rubbing together equal parts of camphor and chloral 
until a semiliquid results. The preparation is an antipruritic remedy 
of value, but if not largely diluted will increase the uneasy sensations 
produced. In other cases an oily or fatty substance will give more 
prompt relief, especially if the eruption has been irritated by scratching 
and tends to persist. Among useful applications may be named the 
linimentum calcis of the pharmacopeia, and cold-cream salve, to which 
may be added fluid extract of grindelia robusta, 1 part to 20 or 30 of 
vehicle; also the dusting-powders, which are described in the chapters 
relating to General Therapeutics and the Erythema ta. These powders 
are the most cleanly of all external preparations in urticaria, and are 
often the only local measures required. Among the Germans sulphur, 
naphtol, and tar-salves are employed in the management of the disease. 

One of the most effective and trustworthy of local applications in 



URTICARIA PIGMENTOSA. 223 

severe urticaria is a starch solution. The starch is first mixed with 
cold water, and is then boiled until the solution is of the consistency 
of thin mucilage. To each pint of this 1 drachm (4.) of zinc oxide 
and 2 drachms (8.) of glycerin are added before ebullition is completed. 
When cool and applied to the surface this solution often gives prompt 
relief. The same is true of a thin solution of boiled oatmeal. 

Such is the empirical treatment of urticaria. It is founded upon no 
rational method of procedure, because the very capriciousness of the 
disease demands and secures relief in one instance by a treatment 
which should be reversed in another. It must be admitted that cases 
occur in which all treatment seems absolutely valueless, often really 
injurious, to the patient. These cases will usually be found to be of 
the relapsing or chronic type. The subjects of this form of disease are 
often plunged into morbid mental states, dreading by day the exacerba- 
tions of the night, brooding over misfortunes experienced or antici- 
pated, worn by loss of sleep, fearful of a generous regime at the table. 
Here the treatment is largely moral, and demands the tact and courage 
of the physician. Travel, change of climate, variation in the routine 
of life, new social surroundings are here valuable. The widow must 
be made to lay aside the heavy crape-veil beneath which her urticaria 
plays ; the solitary patient must secure an acceptable companion for a 
few hours each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at various mineral springs, both 
in America and abroad. Thus, the Karlsbad, Vichy, Saratoga, and 
White Sulphur Springs have all been credited with the production of 
beneficial effects in urticaria. 

Prognosis. — The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest traces of the trouble. In the case 
of children the attack is often at an end in the course of twenty-four 
hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a more formidable affection than a mild attack of 
syphilis. 

URTICARIA PIGMENTOSA 1 (XANTHELASMOIDEA, Fox). 

Symptoms. — This disorder, once regarded as an affection of great 
rarity, has now been recognized in almost all the large centres of 
population. The disease is characterized by the occurrence in early 
infancy, sometimes but a few hours or a few weeks after birth, of 
elevated, rosy or reddish, round or oval wheals and nodules, which are 

1 For complete bibliography, see Blumer, Monatshefte, 1902, xxxiv., p. 213, with 
review of clinical and pathological features of the disease ; and Reiss, Ibid., 1903, 
xxxvii., p. 93; also Duhring's Cutaneous Medicine, vol. ii., p. 300; Wolf, Mracek's, 
Handbuch, vol. i., p. 599 ; and Perrin, La Pratique Dermatologique, vol. iv., p. 772. 



224 



INF LA MM A TIONS. 



succeeded later by flattish or slightly elevated, light or dark-brownish 
or buff-colored macules. Exceptional cases are reported in which the 
disease made its first appearance a number of years after birth. There 
are three tolerably distinct types of the affection : those exhibiting 



Fig. 39. 




Urticaria pigmentosa with xanthoma-like lesions. 

plane lesions with equally flattened maculations ; those with tubercular, 
nodular, or variously sized and shaped wheals ; and mixed varieties, 
the latter being commonest. The mingling of a factitious urticaria 
with lesions long existing and long maculated is not rare. A char- 
acteristic feature of this form of urticaria is the tendency of the wheals 
to recur at the same site, and where pigmentation remains new wheals 
may be produced by irritation. Cases may be classified into those 
accompanied by itching and those not thus characterized ; but these 
differences are due to accidental rather than to essential causes. The 
eruption, which at the outset may appear as late as the third year, 
commonly displays itself first on the neck and shoulders, and then 
rapidly spreads to the head and the extremities, eventually invading the 



URTICARIA PIGMENTOSA. 225 

entire body surface — in well-marked cases even including the mucous 
membranes. The lesions are at first of the usual urticarial type, each 
with delicate zone, but soon lose their distinct contour and elevation, 
and become flatter and pigmented, the color in pronounced cases being 
a distinct yellow, deepening to a decided coffee-and-milk hue. After 
isolated tubercles once acquire the deeper tint they may persist for 
years ; may return in crops ; may even at times be commingled with 
bullae which desiccate in crusts ; may form plaques of infiltration ; may 
be covered with an erythematous blush due to hyperemia of parts long 
affected ; and, when itching is intense, may exhibit the general signs 
of the scratched skin. In a few of the reported cases the nodules 
were modified by vesicles and vesico-pustules, and were followed by 
whitish, instead of pigmented, spots in a smooth or wrinkled and scar- 
like skin. 

Etiology. — The cause is unknown. Among patients the sexes are 
represented nearly equally. Of 83 cases tabulated by Blumer, 1 in 71 
per cent, the disease began within the first year. A congenital predis- 
position is probably an important etiological factor. 

Pathology. — Sections of tubercles have been made by numerous 
observers, including Unna, Raymond, Pick, Thin, and Gilchrist. 
Inflammatory changes similar to those of ordinary urticaria occur, but 
in addition the papillary layer is filled with mast-cells arranged in 
columns, a feature which is characteristic of the process. Brongersma 2 
and Crocker found the accumulations of mast-cells and oedema through- 
out the cutis and extending into the subcutaneous tissue. In appar- 
ently normal areas adjoining the lesions Gilchrist and others found 
an unusual number of mast-cells in the corium. The epidermis is 
unchanged but for an accumulation of pigment in the basal layer of the 
rete. 

Diagnosis. — Urticaria pigmentosa is to be distinguished from the 
slight pigmentation left after well-marked urticaria of later years by 
the beginning of the disease in infancy and by the persistent buff- 
colored tubercles. Xanthoma in all its forms is readily distinguished by 
its persistence in special regions, the eyelids, for example ; by its first 
appearance in many patients at a later period of life than infancy ; and 
by its characteristic chamois-leather-yellow shade. 

Treatment. — No treatment has hitherto been so successful as to 
justify its recommendation. The internal remedies and local applica- 
tions advised for urticaria have been employed with varying degrees of 
success. The best results are obtained after stimulating rather than 
soothing baths, at a later period of life than during the first six months. 
After such stimulation with salt and water or alcohol and water a boric- 
acid dusting-powder may be employed. 

1 Loc. cit. 

2 Brit. Jour. Derm., 1899, xi., p. 179 (with, review of pathology). 
15 



226 INFLAMMATIONS. 



ANGIONEUROTIC (EDEMA. 1 

(Acute Circumscribed (Edema, Acute Idiopathic (Edema, 
Periodic Swelling, Acute Non-inflammatory (Edema, 
Giant Urticaria.) 

This disorder described first by Quincke, and since by many other 
observers, 1 is characterized by the occurrence in successive and recur- 
rent attacks, often acute, rarely persistent in character, of circum- 
scribed, oedematous plaques, developing with acute symptoms and as 
rapidly disappearing. The surface of the affected area is commonly 
reddened in various shades, from a light rosy hue to a livid red. The 
plaques vary in size from that of a small coin to that of the section of 
a large orange, and may involve an entire organ or limb. As a rule, 
no itching is awakened. The swellings are commonly the seat of dis- 
agreeable sensations of fulness, burning, throbbing, or scalding ; and 
if the swelling chance to obstruct a mucous tract (nasal, pharyngeal, 
laryngeal, etc.) there are symptoms of a distressing character, due to 
the transitory occlusion. The disease is occasionally noted in connection 
with urticaria, erythema multiforme, and purpura rheumatica. 

Though each individual outbreak may be rapid of occurrence, the 
disorder responsible for the cutaneous symptoms is unquestionably 
chronic in duration ; and it is the successive and repeated expression 
of its influence upon the skin that in rare cases produces a more or less 
persistent and obstinate cutaneous oedema limited to one portion only 
of the integument. 

The lesions occur upon the conjunctiva, the pharynx, the larynx, 
(where even fatal obstructive consequences may result), and also as 
facial symptoms, especially upon the eyelids and the lips. The lesions 
are to be recognized also upon the extremities, the trunk, the penis, 
the scrotum, and the vulva. In some cases the disorder is well nigh 
universal. When the soles of the feet are involved the erect position 
is impossible without incurring severe pain. The persistent oedema, 
described later and attributed to recurrent attacks of erysipelas and 
lymphangitis, is not of this class. Wende l described a case of acute 
oedema of the dorsum of the hand followed in forty-eight hours by a 
similar lesion on the forearm, and in seventy-two hours by one on 
the face, the attack being accompanied by marked albuminuria and 
haemoglobin uria. 

Etiology and Pathology. — The disease is allied closely to urticaria 
and to erythema multiforme, and many of the causes enumerated in the 
paragraphs devoted to these two diseases may be active in the produc- 
tion of angioneurotic oedema. Individual idiosyncrasy is probably 
the most important factor in the etiology. Inherited tendency to the 
disease has been noted by Quincke, Osier, Essen 3 and others. The 
condition is apparently an angioneurosis. 

1 For bibliography, see Kohn, American Medicine, 1901, ii., p. 997 ; Merklen, La 
Pratique Dermatologique, vol. iv., p. 760. 

2 Jour. Cutan. Dis., 1899, vol. xvii., p. 178. 

3 Berlin, klin. Wchnschrft., 1902, xxxix., p. 1126. 



ANGIONEUROTIC (EDEMA. 227 

Diagnosis. — The disorder should not be confused with erythema 
multiforme, erythema nodosum, giant urticaria, syphilitic and rheu- 
matic nodes, nor with pseudo-lipomas. Between these affections, par- 
ticularly between the three first named, no precise lines of demarcation 
can be drawn, and the diagnosis must be made largely from the con- 
comitant symptoms and from the absence, in circumscribed oedema, of 
itching or pricking sensations, febrile complications, and rheumatoid 
pains. 

Treatment. — Circumscribed cedema is produced under the influence 
of the trophic and vasomotor nerves ; it is, hence, amenable chiefly to 
those remedial agents which tend to influence favorably the nervous 
centres. Internally ergot, iron, nux vomica, quinine, and the sodic 
salicylate are indicated. As some cases are probably toxic in origin, 
efficient elimination should be secured. Diuretics, sudorifics, and 
cathartics are recommended by Besnier and Doyon. The local treat- 
ment is largely that of urticaria. In chronic cases salt and water may 
be applied over the region of the spine by the hands of a competent 
nurse. The salt is moistened with cold or slightly warmed water, 
according to the constitution and temperament of the patient, and is 
then briskly rubbed with a firm hand over the entire spinal region. 
The back is then sponged for several minutes with pure water, at 
first hot and gradually cooled, until the surface is well reddened, when, 
lastly, the surface is dried and the patient made to take moderate exer- 
cise. The result in cases is brilliantly satisfactory. As in chronic urti- 
caria, mental anxiety and distress, especially in women, may be respon- 
sible for a great part of the trouble. 

Circumscribed and Persistent (Edema of a single member or 
region of the body, not of the class of successive and repeated swellings 
noted above, is properly considered with the early stages of elephan- 
tiasis. It results most often from a localized lymphangitis or so-called 
" recurrent erysipelas " (chronic eczema of the face, tumefaction of 
nose and cheeks due to obstruction by tumors of the antrum of High- 
more), and appears upon the face usually as a smooth, shining, whitish 
or reddish tumefaction, ill defined as a rule, in a few cases with fairly 
good definition. The tuberculous toxins may be responsible for some 
cases. The swelling is usually of firm consistence, but can with some 
pressure be indented with the finger. It is always the seat of passive 
hyperemia, never of active inflammation ; but in the case of smokers of 
tobacco and hard drinkers an active inflammation is sometimes awak- 
ened. These patches are rarely painful or tender ; advice is usually 
sought with a view to the relief of the consequent moderate deformity. 
The swellings occur as well upon the lower limbs and breasts of women. 
(Cf. Erysipelas Perstans.) 

The treatment of these cases is by frequent shampooings and em- 
brocations, to stimulate the absorbents, aided by elastic compression. 
Facial deformities of this class are always benefited by abstention from 
the use of tobacco and alcoholic stimulants, the diet at the same time 
being carefully regulated. The nasal cavity, the region of the orbit, 
and the mouth (caries of the teeth, etc.) should always be examined 
with a view to the removal of the cause. 



228 INFLAMMATIONS. 

DERMATITIS. 

(Ger. y Hautentzundung ; Fr., Dermatite, Dermite.) 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under dermatitis, however, are grouped those inflamma- 
tions only in which the result is plainly due to a direct influence 
exerted upon the skin by thermal, chemical, or mechanical agencies. 
The inflammatory process may involve the superficial or the deep por- 
tion of the integument, or it may extend to the subcutaneous tissues, or 
even deeper. The symptoms vary with the nature of the cause, the 
extent and degree of its influence, and the circumstances attending its 
operation. There may be simple hyperemia and oedema of a few hours' 
duration, or there may follow papules, vesicles, bullae, pustules, and 
crusts. These lesions may be situated on an intensely reddened and 
much swollen base. In severe cases ulceration, gangrene, and exten- 
sive scarring may occur. With these phenomena there may be general 
symptoms of mild or of severe grade, due to the influence exerted by 
the local process upon the general economy. When the exciting cause 
is of moderate intensity but is long continued there results a chronic 
dermatitis in which the skin may be more or less thickened and infil- 
trated, dull red in color, and covered with fine adherent scales. 

DERMATITIS TRAUMATICA. 

External violence, varying in character and severity, is capable of 
inducing dermatitis, the symptoms of which differ in degree, though 
their career is, in general, the same. In this list are included the in- 
flammations produced by surgical interference with the continuity of 
the integument ; excoriations caused by scratching, by friction with 
garments and other articles injuriously acting upon the skin ; by the 
various implements handled in the trades ; and by the bites or the 
stings of beasts, insects, reptiles, and fishes, when the result is trau- 
matic and not toxic in character. These injuries may be in the form 
of contusion, blow, concussion, pressure, puncture, incision, or lac- 
aration, and the consequences are declared in heat, swelling, redness, 
and pain ; in itching, burning, stinging, or pricking sensations ; with 
subsequent inflammatory symptoms varying in grade from mild and 
transitory hypersemia and exudation to the severer grades of inflam- 
mation mentioned in the preceding paragraph. 

DERMATITIS VENENATA. 

Certain medicinal and other substances applied to the external sur- 
face of the skin are capable of exciting inflammation by operating either 
as caustic, irritant, toxic, or even traumatic agents. 

Symptoms. — Careful observation of a typical case of dermatitis 
venenata soon after the onset of symptoms will disclose the exact sur- 
face of contact, such surface being delicately outlined by a reddened, 
tolerably well-defined line, within the limitation of which will be seen a 



DERMATITIS VENENATA. 229 

slightly tumefied, erythematous area, at times displaying closely packed, 
pin-point-sized papules, vesicles, or pustules. As the dermatitis pro- 
gresses it is not necessarily limited to the surface with which the irritant 
has come in contact. The inflammation may extend to adjacent por- 
tions of the skin, or, as a result of absorption and consequent toxic effects 
or of reflex nervous irritation, it may appear on distant surfaces of the 
body. Numerous types of cutaneous lesions — macules, pustules, papules, 
vesicles, bullae, wheals, scales, crusts, free serous and purulent discharges, 
subcutaneous abscesses, and even gangrene with sloughing — may occur, 
the result being largely proportioned to the character of the agent pro- 
ducing the injury and to the susceptibility of the individual. 

Etiology. — Among the sources of dermatitis venenata may be named 
most of the strong acids and alkalies, cro ton-oil, cantharides, mustard, 
tartar emetic, mezereon, the compounds of mercury, arnica, turpentine, 
ether, chloroform, tarry compounds, resorcin ; many of the dyes, several 
members of the rhus family (Rhus toxicodendron, poison-ivy, and Rhus 
venenata, poison-sumach), the nettle, the smartweed (Polygonum pune- 
tatum), cowhage (Mucuna pruriens), and glass in fine powder or in deli- 
cate filaments, such as are thrust into the skin when handling certain 
articles of Venetian glassware. This list might indefinitely be extended, 
as there are few articles which are not capable of producing some irri- 
tation of the surface of the skin if applied to it with sufficient vigor 
and for a certain period of time ; and in some cases it is difficult to 
decide whether the effect is more traumatic than toxic. An almost 
equally long list of substances of animal origin might be named having 
poisonous effects upon the integument, such as decomposed or am- 
moniacal urine, feces, ichorous pus, and pathologically altered secre- 
tions from the uterus, the eye, ear, nose, etc. 

A few of the more common causes of dermatitis are : the use of 
soap containing an excess of alkali or even minute particles of bone 
for laundry, toilet, or other domestic purposes, as also several of 
the proprietary articles sold in the shops for similar employment. 
Stockings and other undergarments dyed with anilin, picric acid, 
chromium, or arsenic ; hair dyes, the leather lining of the inside of the 
hat or the cap, and the painted toys to which the lips of children are 
applied, will beget mischief in the various regions of contact for each. 
Duhring reports cases in which the dyestuff in the lining of shoes 
penetrated the material of stockings in women, and produced dermatitis 
of the feet or the legs. 

The tincture of arnica, an article much used as a domestic applica- 
tion for contused and incised wounds of a simple character, has pro- 
duced very serious annoyance in some cases, two such having been 
recently presented at the authors' clinic. The number of these acci- 
dents is annually increasing. Cartier l reports excessive erysipelatous 
swelling, a phlyctenular eruption, and submaxillary adenopathy result- 
ing from the external use of arnica. Beauvais reported to the Paris 
Medical Society gangrenous results in one case. Buchner believes this 
poisonous action to be due to insects (particularly the Atherix maculatus) 
found in the calyx of the arnica-flower. Other native plants, a large 
1 Lyon med., April 13, 1884. 



230 INFLAMMATIONS. 

number of which are enumerated in a valuable monograph and sup- 
plemental list by J. C. White/ are similarly effective. Wesener, 2 
reports that the Malacca bean-tree (Anacardium orientate) furnishes a 
caustic oil, called " cardol," or " cardoleum pruriens," that produces, 
after application to the skin, vesicles and vesico-pustules which contain 
cardol and terminate by crusting. He reports a generalized eruption, 
beginning on the face, due to this cause. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive troubles. Among these antiseptics may be named iodo- 
form, which has produced erythema, vesicles, pustules, and wheals. 3 
Carbolic-acid and corrosive-sublimate dressings have had similar effects. 
The prolonged application of weak solutions of carbolic acid is fol- 
lowed occasionally by gangrene of the area. 4 Formalin causes vesicular 
and pustular lesions of the fingers in predisposed individuals. Ortho- 
form may give rise to lesions similar to those caused by iodoform, with 
the occasional production of gangrene. 5 Many of the articles employed 
therapeutically by the dermatologist should be placed in the same 
category. Green, 6 of London, reports oedema of the skin followed by 
desquamation, resulting from the application to it of the ointment of 
ammoniated mercury in the strength of 2 drachms (8.) to the ounce (30.). 

Leszinsky reports a case of dermatitis of the face folloAving the use 
of a " triple extract of heliotrope" as a toilet-preparation. 

An exceedingly common source of dermatitis is urine retained upon 
underclothing of adults. A persistent dermatitis of the scrotum, the 
perineum, or the inner faces of the thighs in either sex, always calls 
for examination as to whether a few drops of urine are not left in con- 
tact with such underclothing after each act of micturition. Fistulse, 
urinary incontinence, prostatic disease, " stammering of the bladder/' 
imperfect finish of the coup de piston in men, especially after a gonor- 
rhoea and similar troubles, are all to be remembered. 

The eruption produced by the Poison-ivy and other varieties of 
rhus is almost exclusively an American disease; and from its frequency 
in the United States has attracted a great deal of attention. A certain 
degree of susceptibility to the poisonous action of the plant is requisite 
for the production of its effects, as some individuals can handle the 
leaves of the plant with impunity, while others, it is claimed, are 
affected by its exhalations within a circle having a radius of several 
feet. It is, however, difficult to demonstrate the truth of the last state- 
ment, suspecting, as one may, that such instances may be cases of con- 
tact with other than the suspected plant. The parts commonly affected 
are the hands and the regions to which the latter are carried, such as 
the face, the genitals, the arms, the thighs, and the neck ; barefoot 
children suffer in the feet and the legs. Usually the symptoms are 
developed in the course of a few hours, and they consist of eryth- 

1 Dermatitis Venenata, Boston, 1887; and Jour. Cutan. Dis., 1903, xxi., p. 441. 

2 Deutsche Arch. f. klin. Med., xxxvi., p. 578. 

3 See paper of E. W. Taylor, read before the New York Academy of Medicine, 1887. 

4 Harrington, Amer. Jour. Med. Sci., 1900, cxix., p. 1, report of 18 cases and 
review of 118 cases from literature. 

3 Dubreuilh, La Presse med., 1901, liii., p. 233. 
6 Brit. Med. Jour., 1884, i., p. 853. 



DERMATITIS VENENATA. 231 

ematous patches ; scanty or profuse vesiculation with abundant serous 
weeping after rupture of the lesions ; swelling, oedema, and disfigure- 
ment ; and intense burning and itching sensations. Serious effects are 
occasionally produced. Deeply attached scars may result from subcu- 
taneous abscesses of parts greatly swollen. Occasionally in particu- 
larly sensitive skins the eruption spreads from the skin-surface affected 
by the poison to that where presumably none has been applied. It 
should be remembered, however, that articles of clothing may for brief 
periods of time furnish sources of further trouble, being worn at the 
moment of contact with the plant, then laid aside, and, the occasion 
quite forgotten, being subsequently employed. Thus, a pair of un- 
dressed-kid gloves after lying for two weeks untouched have sufficed 
to awaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing of 
lacquered ware. This lacquer is manufactured from a rhus varnish. 
A few instances of such dermatitis have occurred in America from 
handling newly imported articles of this class. 

Diagnosis. — An acute dermatitis appearing suddenly on regions of 
the body readily exposed to toxic agents should always arouse sus- 
picion of dermatitis venenata. A history of contact with some irritat- 
ing substance can usually be obtained. The inflammation in the begin- 
ning is limited to the areas with which the toxic agent came in contact, 
is often asymmetrical, and has no relation to the general health of the 
patient. The process often reaches the point of greatest intensity 
within a day or two after its first manifestations, and subsides soon 
after removal of the cause. 

The peculiar features of ivy-poisoning have been described in a 
monograph on the subject by White, of Boston. 1 According to this 
author, the lateral surfaces of the digits first exhibit the symptoms of 
the eruption, later the dorsal surfaces, and latest the thickened palms. 
The efflorescence also is more irregularly distributed, more uniformly 
vesicular, and the vesicles are less transparent than in eczema. The 
lesions, moreover, are more vesicular and less papular at the outset, 
and, though suggesting papules by their situation in the palm, are in 
that situation readily made to exude serum by puncture with a needle. 

Treatment. — Internal medication is not required. The local treat- 
ment is that of acute eczema. Black wash (preferably dilute), solution 
of sugar of lead, or oleated lime-water may be employed at first, and be 
followed later by dusting-powders. In two instances under our observa- 
tion a dermatitis due to formalin, and which had resisted other treat- 
ment for months, yielded readily to radiotherapy. A number of other 
cases due to unrecognized agencies have responded equally well to this 
treatment. (For technique, see Psoriasis.) 

In ivy-poisoning the application of an alkali, for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch), should evidently be considered solely with 
a view to prophylaxis, as it is difficult to understand how such neu- 

1 New York : D. Appleton & Co., 1878, from the March number of N. Y. Med. 
Jour, of the same year. 



232 INFLAMMATIONS. 

tralization can control the inflammatory process after its onset. The 
late Prof. Babcock, of Chicago, a frequent suiferer from this disease 
following his extended botanical excursions, first made known the value 
of an ointment made by incorporating a decoction of the inner bark of 
the American spice-bush {Benzoin odoriferum) with cold-cream salve. 
It affords prompt relief in cases in which it is employed, the difficulty 
lying in securing the bark of the shrub in its young and tender 
state. 

Many topical remedies have been vaunted as specifics for the relief 
of this disorder, from the brine of a pork-barrel to a decoction of the 
leaves of the plant itself. As the eruption usually subsides when the 
skin is protected and not irritated by the local treatment, it is not dif- 
ficult to explain the result in most cases, though it is possible there is a 
parasitic or toxic element in the poison. Complete covering of the 
affected area with flexible collodion frequently is effective, and if 
applied to the lesions when they first appear often will abort the dis- 
ease. In later stages, care should be taken in opening the vesicles 
to prevent their contents from coming in contact with unaffected 
areas of the skin. After emptying the vesicles with a sterile needle, 
the involved areas may be painted several times with a 50 per cent, 
solution of ichthyol, and when dry covered with a dusting-powder and 
light bandage. Sodium hyposulphite, 1 drachm (4.) to the ounce (30.), 
often gives good results when applied as described above or as a wet 
dressing Corrosive-sublimate lotions ; saturated solution of boric 
acid; Carron oil; tincture of iron; bromine, 15 drops (1.) to the 
ounce (30.) of olive-oil (Brown) ; dilute nitric acid ; sodium bicarbon- 
ate ; saturated solution of potassium chlorate ; and grindelia robusta, 1 
drachm (4.) of the fluid extract to 8 ounces (250.) of water, have each 
been found useful. 

DERMATITIS CALORICA. 

Under this title are included those affections of the skin induced by 
extremes of thermal variation. 

Unduly high temperatures produce in the skin redness in varying 
shades and a slight degree of swelling, the color not completely disap- 
pearing under pressure. If the exciting agent be withdrawn before 
further effects are induced, the color first deepens, then becomes paler, 
and in twenty-four hours the process is usually concluded with a very 
delicate and transitory resulting pigmentation. 

Rays of heat and heated objects at a temperature from 125° to 
175° F. produce immediately, or after a brief interval, first, an erythema, 
which disappears when the source of the heat is removed; second, 
after more prolonged exposure, the symptoms of active inflammation 
and exudation. Vesicles or bulla?, isolated or confluent according 
to the severity of the cause, may rise from a reddened skin which 
is usually intensely painful. These lesions are persistent or are 
transitory, and are generally filled with a clear serum, which exudes 
and dries into crusts after rupture of the chamber in which it was 
imprisoned. At other times the exudation is so abundant that the 



DERMATITIS CALORIC A. 233 

epidermis rises in broad plates, from beneath which the serum is ex- 
uded. This process may terminate by a free production of pus upon 
the surface and gradual resolution. Adenopathy is a frequent concom- 
itant symptom. In such dermatitis of extensive areas of the skin the 
intensity of the process may awaken a violent fever, or death may 
result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality ; or, as 
Kaposi describes it, is dense, coriaceous, and white as alabaster, 
though upon the eschar some vesicles appear, and by their presence 
suggest a false conclusion as to the vitality of the tissues upon which 
they rest. In from eight to ten days the slough is removed by sup- 
purative processes, and the scene is closed by the usual phenomena of 
granulation and cicatrization. The characteristics of the scar thus 
produced are : its great irregularity, its tendency to stellate radiation, 
and the production of ridges, folds, pockets, and bridles. 

Burns involving one-third the body-surface are of grave portent, 
and those affecting one-half the body are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little complaint 
of pain. The causes of death in these fatal cases are generally obscure, 
as the post-mortem results are usually negative. Gastric and duodenal 
ulceration, however, is often recognized. Overheating of the blood, 
heart-paralysis, oligocythemia, and actual destruction of leucocytes 
have all been supposed to be effective in bringing about dissolution. 
In cases in which life is prolonged to the third day the complications of 
pyaemia, erysipelas, and tetanus may arise. Lastly, exhaustion fol- 
lowing fever, suppuration, hemorrhage, and visceral affections may 
lead to fatal results. 

Treatment. — In the treatment of the simplest burns, rest, lotions of 
lead-water, and cool water, with the application of compresses, are 
usually sufficient to secure relief; occasionally, dusting-powders may 
advantageously be substituted. In the cases in which serum is brought 
rapidly to the surface, with the production of vesicles and bullae, the 
latter should be punctured skilfully to give relief to the tension by the 
evacuation of their contents, but the roof-wall should be preserved, as 
it may subsequently form an attachment to the exposed derma be- 
neath. The indications then are to exclude the air as perfectly as 
possible and to prevent suppuration, indications which are admirably 
met by the application of a mixture of equal parts of olive oil, and lime- 
water containing \ per cent, of carbolic acid. Continuous immersion 
in water having the temperature most agreeable to the patient, as 
practised by Hebra in cases of severe and extensive burning, produces 
a speedy and certain amelioration of the pain and a favorable condition 
of the wounds, though it does not avert a fatal issue in any dangerous 
case. 

The strictest antiseptic precautions are demanded when the suppura- 
tive process in the skin is both active and extensive. Disinfection 
with a 5 per cent, solution of carbolic acid, or a 2 per cent, resorcin 
solution, should be followed by the application of protective silk wet 
with a 5 per cent, solution of sodic biborate or bicarbonate, and the 



234 INFLAMMATIONS. 

whole enveloped either in borax-lint, antiseptic (mercuric iodide) wool, 
carbolized gauze, or salicylated cotton ; over all, impermeable rubber 
tissue should be wrapped. Instead of the protective silk, it is often 
better to use strips of sterile moist rubber tissue, J- of an inch wide. 
These are laid smoothly and evenly over the surface with narrow 
spaces between each. The first layer then is crossed by a second at 
right angles to the first. The surface is thus practically covered 
with the rubber tissue, leaving, however, at each crossing of the 
strips small openings for the escape of secretion. Boric acid, or other 
feebly antiseptic solutions, may then be applied and changed as often 
as necessary without damage to the surface beneath. 

Nitzsche 1 first disinfects the burnt surface thoroughly with carbolic 
acid, having previously protected the blebs, after which it is covered 
with a thick varnish of linseed-oil and litharge mixed by the aid of 
heat with 5 per cent, of salicylic acid. When this coat is dry a sec- 
ond coat is applied, and the whole is finally covered with a thick 
layer of wadding retained in place by an elastic bandage exercising 
moderate compression. Cicatrization progresses beneath the dress- 
ing without changing the latter. When suppuration occurs the 
upper layer of wadding is removed, and dried salicylic acid in 
powder is sprinkled over the surface, the Avadding being afterward 
reapplied. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

Congelatio, or dermatitis from congelation, presents usually in 
the milder forms circumscribed erythematous patches or plaques, gen- 
erally recognized under the name of Pernio, or chilblain, seated upon 
the digits or, more rarely, upon the face, and occasioning a disagree- 
able sensation of heat, smarting, or itching, especially after the chilled 
part has been warmed. 2 Chilblains are bluish or purplish red in 
color, and are often seated on a slightly oedematous integument. They 
are generally cool to the touch when subjectively hot. Authors have 
claimed that anaemia is a chief predisposing cause of the complaint, but 
it frequently occurs in perfectly healthy young people. Sir Erasmus 
Wilson has suggested that some cases of so-called " lupus erythema- 
tosus " of the hands belong to this category. 

In the second grade of inflammatory reaction, following the state of 
contracted blood-vessels and pallid integument produced immediately 
by the action of cold, bullae and vesicles form, with underlying ulcers 
in severe cases. 

In the third grade gangrene may occur, with and without the forma- 
tion of bullae. The frozen part may become insensitive, white, and 
cold, without the circulation in it of blood- and lymph-currents. From 
this condition reaction occurs, with the formation of an eschar, differing 
after the death of the patient according to the severity of exposure to 
cold. If, however, beside the interference with the circulation, the tissue 
itself has been destroyed, when reaction occurs the part falls at once 

1 Deutsche med. Zeit., 1881. 

2 Consult the chapter devoted to the Erythema!' 



DERMATITIS MEDICAMENTOSA. 235 

into gangrene ; or there form bullae larger than those described above, 
filled with sanguinolent serum ; or the skin is smooth, marbled with 
bluish lines, whitish, cold, and insensitive. Mortification ensues, 
followed by the well-known phenomena of the " line of demarcation," 
and, in favorable issues, suppurative separation of the dead part, gran- 
ulation, repair, and cicatrization. As the injuries induced by conge- 
lation are more frequent upon the extremities, the bones, especially 
those of the digits, largely participate in the losses of tissue. Septi- 
caemia and a fatal result may follow. 

Chilblains are treated internally by the ferruginous tonics, particu- 
larly the tincture of iron, externally by stimulant applications, such 
as those containing iodine, camphor, carbolic acid, tincture of benzoin, 
and balsam of Peru. Kaposi recommends : 



R 



Pulv. camphorse, 


gr. x; 




Cretse praeparat., 


3j; 


30 


01. lini, 


fgij; 


60 


Balsam. Peruvian., 


ttlxx; 


1 



66 



33 M. 



Frictions, with or without medication, are generally useful. The 
parts are to be carefully protected from pressure and undue friction- 
effects. 

Painting the part frequently with a 50 per cent, aqueous solution 
of ichthyol, or the application of an ointment containing 2 drachms 
(8.) of ichthyol to the ounce (30.) gives good results in many cases. 

Dilute nitric acid and peppermint-water in equal proportions, 
painted over the part for three or four successive days, have been 
recommended by Lapatin for the treatment of frost-bitten fingers and 
toes. Hydrochloric and pyroligneous acids, lemon-juice, 50 per cent., 
and stronger solutions of lead acetate, both in lotions and poultices, 
are also recommended. Meurisse advises in the management of both 
severe ambustio and congelatio that goldbeater's skin be employed over 
any salves or lotions applied to the affected surface. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction performed in an apartment the air of which is 
cool, to prevent too energetic reaction. Friction with snow is em- 
ployed with safety in America and on the steppes of Russia, where 
these accidents are frequent and are grave in results. Perseverance 
for hours in this course is often rewarded with success in apparently 
desperate cases. Antiseptic dressings are usually demanded when 
sloughing and ulceration ensue. 

DERMATITIS MEDICAMENTOSA. 

(Drug Eruptions. Ger., Arzneiexantheme ; Fr., Eruptions 

MEDICAMENTEUSES.) 

The importance of recognizing the fact that a given eruption is 
produced by an ingested drug can scarcely be overestimated from the 
point of view of the diagnostician. The errors committed in this con- 
nection are so frequent and so annoying to the patient that it is neces- 
sary for the physician to inquire very carefully, before treating any 



236 INFLAMMATIONS. 

cutaneous disease, as to the medicaments previously swallowed by the 
patient, and also to be prompt to connect any aggravation of a cutane- 
ous disease with remedies ordered by himself for internal use. The 
following is but an imperfect list of the drugs the internal adminis- 
tration of which may be followed by an exanthem — imperfect, because 
without question many have yet to be recognized as possessing such an 
action. As to the modus operandi of such medicinal agents, for the 
most part our knowledge on this subject is purely conjectural. Some, 
for example potassium iodide, are eliminated in part by the glands of 
the skin, and presumably have thus a local effect upon such emunc- 
tories ; others, and in this class, probably, should be included quinine, 
induce an urticaria scarcely to be distinguished from an urticaria ab 
ingestis. Some operate, possibly, in either or both ways at different 
times or in different individuals. The absurdity of supposing that 
any disease can be " driven out " by the ingestion of such drugs should 
be relegated to the specious ignorance which first framed such an 
hypothesis. 1 

Acids. — The acids capable of producing macules, papules, erythema, 
desquamation, etc., are carbolic, nitric, tannic, benzoic (and sodium ben- 
zoate), and boric (and sodium borate). 

Modadewkow reports a case in which the pleura was washed out with 
a 5 per cent, solution of boric acid, a part of which was not removed. 
There occurred as a result an erythematous rash over the face, the 
trunk, and the extremities. 

Aconite. — This drug is said to be productive at certain times of 
marked diaphoresis with the occurrence of vesiculation and consider- 
able itching. The diaphoresis in an irritable skin may be responsible 
for the trouble. 

Antifebrin or Acetanilid occasionally produces an erythematous or 
maculopapular exanthem, or, when long continued, may cause partial 
cyanosis. 

Antipyrin and Other Remedies of its Class (manufactured by the 
action of glacial acetic acid upon the petroleum-products). — Ernst 2 has 
been followed by many observers in recording rashes resulting from 
the administration of antipyrin. The symptoms are discrete and con- 
fluent patches of bright-red, scarlatiniform, erythematous, and pru- 
ritic macules or papules. Veiel 3 reports oedema with bullae upon the 
lips and toes, and over the palate, with urticarial lesions of the palms 
and soles, after ingestion of antipyrin. Brocq, Darier, and others have 
reported cases in which antipyrin has produced a more or less persist- 
ent erythema in the form of isolated, scattered, sharply defined plaques. 
These plaques are usually few in number, and they tend to return in 
the same sites whenever the susceptible individual ingests the drug. 
The redness and pigmentation may persist for several weeks. Wick- 
ham reports an antipyrin-rash which simulated perfectly a macular 
syphiloderm. 4 

1 For full details and bibliography of this subject, consult the treatise on Drug- 
eruptions, by Prince A. Morrow, New York, 1887; and chapter by Ehrmann in 
Mracek's Handbuch, vol. i., p. 639. 

2 Centralb. f. klin. Med., 1885. 3 Archives, 1891, xxiii., p. 33. 
4 Cf. Berliner Monatshefte, 1902, xxxv., p. 137 (with review of literature). 



DERMATITIS MEDICAMENTOSA, 



237 



Antitoxin. — Following injections of diphtheria-antitoxin, erup- 
tions occur which are erythematous, scarlatiniform, morbilliform or 
urticarial. Stanley l reports that out of five hundred cases of diph- 
theria in which antitoxin was used, in about one-fourth of the number 
there appeared, as a rule in about two weeks, though sometimes earlier, 
an exanthem of some form, the most frequent type being that of 
erythema marginatum, which occurred in areas commonly affected 
by psoriasis. In many instances pigmentation persisted after disap- 
pearance of the erythema. The exanthem frequently began on the 
face. Other erythematous and urticarial types, as well as scarlatini- 
form and morbilliform eruptions, were seen. Tuberculin and other 
toxins and antitoxins occasionally cause similar eruptions. 

Fig. 40. 




Generalized pigmentation and keratosis following long-continued use of arsenic. 

Arsenic. 2 — Erythematous, vesicular, papular, and much more rarely 
pustular, bullous, and ulcerative lesions occur upon the face, the 

1 Brit. Med. Jour., 1902, L, p. 386. 

2 Cf. Brooke-Roberts, " The Action of Arsenic on the Skin as Observed in the 
Recent Epidemic of Arsenical Beer-poisoning," Brit. Jour. Derm., 1901, xiii., p. 121. 



238 INFLAMMATIONS. 

back, and the hands after the ingestion of arsenic. The well-known 
effects of the administration of the drug in toxic doses upon the 
mucous membranes of the eyes, nose, and mouth need not be 
described in this connection, nor yet the grave gangrenous symptoms, 
with osseous necrosis, that have been observed in workers in the 
metal. 

A bright-red, scarlatiniform blush with a few isolated vesicles has 
covered both shoulders of a young woman with a delicate skin after 
taking three medicinal doses of Fowler's solution, the eruption being 
present but less distinct upon her face and hands. In two cases the 
rash in polymorphic type was limited to the hands alone. 

Young patients who have taken arsenic in the largest medicinal 
doses for relief of chorea often present as a result a dark discoloration 
chiefly of the skin of the chest and the neck, but also of other parts of 
the body. This discoloration is suggestive of the bronzing seen in 
Addison's disease. In some instances there are no other cutaneous 
symptoms. Guaita and Liege noted these phenomena usually in the 
fifth month after ingestion of the drug. 1 

Long-continued use of arsenic may produce keratosis of the palms 
and soles of a severe grade, obstinate character, and occasionally grave 
results. Administered for relief of psoriasis, the resulting keratoses 
have later developed into epitheliomata of malignant type. 2 

By far the largest number of rashes are, however, produced in per- 
sons previously suffering from the cutaneous disease for the relief of 
which the drug is administered. Here the toxic effect is declared by 
either — first, increased hyperemia of the skin, visible in an erythema- 
tous patch, or beneath the scales of a squamous patch, or as an areola 
of bright-red hue about any aggregation of lesions ; second, by simple 
aggravation of the type of a disease already in existence (recurrence 
of acuity in a subacute eczema) ; third, by rapid peripheral extension 
of a disease which had previously been well limited in contour ; fourth, 
by converting a disease exhibiting uniformity of lesions into one char- 
acterized by multiformity. Each of these results might be illustrated 
by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper-hangings, and reported by Brown, 3 there were, curiously, no 
cutaneous symptoms. 

Belladonna. — The well-known erythematous, scarlatiniform, or red- 
dish efflorescence produced by belladonna and its alkaloids is usually 
limited to the upper segment of the body, but it may become general- 
ized. It is said to occur more frequently in children, probably because 
it has been administered largely to individuals of that age under the 
delusion that it is useful as a prophylactic in scarlatina. Very dis- 
agreeable and even dangerous results have followed the instillation into 
the eye of atropine as a mydriatic, the rash being accompanied by con- 
stitutional symptoms. 

1 Cf. Hamburger " Arsenical Pigmentation and Keratosis," Johns Hopkins Hosp. 
Bull., 1900, xi., p. 87. 

2 Hartzell, Amer. Jour. Med. Sci., 1899, cxviii., p. 265; and Darier, Annales, 1902, 
iii., p. 1126. 

3 Paper read before the Boston Society for Medical Observation, March 6, 1876. 






DERMATITIS MEDICAMENTOSA. 239 

Boric Acid. 1 — Erythema, papules, vesicles, bullae, and lesions resemb- 
ling those of erythema multiforme (Fordyce) are reported as following 
the ingestion, or absorption, of boric acid. A mild form of acute 
exfoliative dermatitis, with temporary loss of hair, is recorded as 
occurring after prolonged use of the remedy. 

Bromine and its Compounds. — A full account of the cutaneous 
effects of bromine and its compounds, when administered internally, 
is contained in a paper on medicinal eruptions, read in 1880, by 
Van Harlingen, of Philadelphia, before the American Dermatological 
Association. Acneiform lesions, pustules, macules, maculo-papules, 
papules, eczemaform moist patches, furuncles, urticarial wheals, scales, 
and ulcers have been induced by swallowing the bromides of potassium, 
sodium, ammonium, and lithium. By far the commonest are the 
acneiform and pustular lesions, occasionally accompanied by pruritus, 
which appear upon the face and the upper portion of the trunk, 
though the rash maybe very distinct upon the genital region. Duhring 
reports an interesting observation of a patient in whom the eruption 
simulated closely the maculo-papular syphiloderm, the patient having 
taken a bromine salt for three years. The eruption first appeared 
within five or six days after decreasing the dose. Kaposi observed 
a case of bromide-rash in a nine-months-old suckling, the mother 
having taken 120 grammes of potassium bromide in two months, 
herself exhibiting no traces of eruption. 

A remarkably characteristic exanthem is produced by the admin- 
istration of potassium bromide, especially to infants and young chil- 
dren. The lesions are condylomaform, quite numerous, conspicuous 
about the face and neck, where they are packed closely together, but 
they are also seen on other parts of the body. The small coin- to nut- 
sized elevated nodules are usually flattened ; and they often resemble 
carbuncles, as they have a cribriform summit on which multiple points 
of imprisoned pus are visible. This rash, though rare, has been care- 
fully studied and well illustrated by chromo-lithographic reproductions. 

T. C. Fox and Gibbes report these condylomaform nodules in the 
case of an infant in which the histology of the lesions was carefully 
studied ; and Fay in a child eleven months old also recognized an 
exanthem which had been mistaken for molluscum epitheliale. These 
lesions are somewhat similar to the condylomaform rash seen in chil- 
dren after the administration of potassium iodide. The lesions may 
appear for some weeks after the drug has been discontinued. 

Browse, of Cambridge, England, recommends for relief of these 
symptoms the application of a solution of salicylic acid, 1 grain to the 
ounce (0.066-30.) of water, frequently applied on lint, he having suc- 
cessfully treated in this way sores as large as the palm of the hand. 

Cannabis Indica. — The only instance reported of an eruption pro- 
duced by the ingestion of this drug was observed by one of us in the 
case of an adult male, who was covered extensively with papulo-vesicular 
lesions after swallowing 1 grain (0.066) of the extract. 2 

1 Cf. Wild, Lancet, 1899, i., p. 23 (with bibliography). 

2 New York Med. Kecord, May 11, 1878. 



240 INFLAMMATIONS. 

Cantharides. — Erythematous and papular eruptions are reported in 
a few instances. 

Capsicum. — Erythema results occasionally. Allen reports a papulo- 
vesicular eruption following the internal Use of the drug. 

Chloral. — An erythematous rash is the commonest of the eruptions 
produced by chloral, though wheals, red and yellowish papules, vesi- 
cles, pustules, and petechial blotches have been observed. The rash 
occurs upon the face, the neck, the trunk, and the limbs, of the latter 
especially on the extensor surfaces. In a man of advanced years 
and totally deaf, who had slept only under the influence of chloral for 
four years, discrete scaly patches as large as saucers covered the hands 
and the lower extremities. 

Martinet 1 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face and neck, the front of the chest, the extensor surfaces of 
the larger joints, and the dorsum of the hands and feet. There was 
no pyrexia nor indisposition, but in some cases there were dyspnoea 
and cardiac palpitation. 

Chloralamid. — Pye-Smith reports a case in which this drug pro- 
duced a scarlatiniform eruption, involving the mucous membranes, 
accompanied by fever, and terminating in free desquamation. 

Chloroform. — During inhalation an erythema of short duration, and 
rarely, purpuric spots are noted. 

Cod-liver Oil. — According to Farquharson, 2 cod-liver oil after 
being swallowed is capable of producing an acne. This result is trace- 
able to the use of inferior qualities of the oil. 

Condurango. — Guntz 3 reports the occurrence of furuncular and acnei- 
form lesions in twenty patients out of one thousand who were taking 
condurango for the relief of syphilis. 

Copaiba and Cubebs. — Occasionally the ingestion of copaiba is fol- 
lowed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering the 
body-surface. The rash may occur in dark mulberry-red petechia?, and 
always is accompanied by pruritus. Inasmuch as the drug often is 
administered for the relief of a venereal disorder not syphilitic, care 
should be taken not to confound the eruption it may excite with the 
early macular syphiloderm. Cubebs is followed much more rarely by 
a similar result. 

Digitalis. — In Behrend's treatise on Diseases of the Skin 4 reference is 
made to cases in which macular and maculo-papular rashes succeeded 
the ingestion of digitalis. 

Ergot. — This drug rarely gives rise to vesicles, pustules, small furun- 
cles, or petechia?. Circumscribed areas of gangrene on the extremities 
are more common. 

1 These de Paris, 1879. 

2 Brit. Med. Jour., 1879, i., pp. 223, 266. 

3 Vierteljahr., 1882, ix. 

4 Braunschweig, 1879. 



DERMATITIS MEDICAMENTOSA. 



241 



Iodine and Its Compounds. 1 — Potassium iodide is responsible for the 
larger number of all eruptions among medicinal rashes. The frequent 
employment of this drug and the very marked influence it possesses 
over the skin render the study of these morbid results important. 



Fig. 41. 




Papilloma, due to the ingestion of the iodine compounds. 

Unlike many of the other substances in the list of drugs, the iodine 
compounds are followed by some species of rash in probably the larger 
number of all persons who swallow them. As is true also with the 
bromine compounds, the eruption may persist, or even first appear, 
after the drug has been discontinued. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or may be circumscribed subcutaneous 
abscesses. In appearance the rashes produced by iodine and its com- 
pounds may simulate those of every other dermatitis. 

The macular rash is seen best fully developed over the upper 

1 Of. E>. W. Montgomery, Trans. Med. Soc. of State of Cal., 1900, review of subject 
with bibliography^ and Kosenthal, Archiv, 1901, lvii., p. 3, review of subject with 
account of histological changes in one case. 

16 



242 INFLAMMATIONS. 

extremities in discrete erythematous patches or as a diffuse blush. 
Generally the rash is displayed symmetrically. The hands are often 
affected, and suggest in appearance the hands of the anilin-worker. 
The rash assumes at times the papular type with special production of 
papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence, 
with numerous minute discrete vesicles upon the surface of the skin. 
Eczemaform eruptions with abundant serous exudation are also reported. 

A number of cases are on record in which the administration 
of the drug was followed by the production of bullae. Bumstead, 
Taylor, Duhring, Tilbury Fox, Finny, and one of us have described 
such bullae in adults as well as in children. 1 Hallopeau 2 also reports 
a fatal case in which a bullous eruption followed the ingestion of 
potassium iodide. The eruption occurred chiefly about the head and 
neck and the upper extremities. The significant rarity of vesicu- 
lar and bullous lesions in acquired syphilis suggests that at least some 
of the cases on record were those of rashes induced by the remedy 
given for the relief of the disease. 

A careful analysis of these bullous rashes leads to their division into 
three categories : first, those occurring, often with fatal results, in 
cachectic adult patients ; second, those occurring as part of the eruptive 
lesions in a polymorphic group ; third, those occurring in well-nour- 
ished children, and taking on the appearance of molluscum epitheliale 
and condyloma-lesions, usually compounded of papulo- vesicles and 
pustules. Erythanthemata of a similar type have also been recognized 
after the ingestion of potassium bromide by infants. 

The pustules induced by the administration of iodine compounds are 
seen chiefly upon the face, the neck, the trunk, and the arms. They 
are usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular 
violaceous mass nearly two inches in diameter. Large, cherry-sized, 
tubercular or papillomatous elevations abruptly rising from the surface 
of the integument may present a cribriform structure, which shows the 
open ducts of several suppurating follicles (chin, cheek, nose). A few 
cases are reported in which fungating tumors were found, producing 
an appearance almost identical with that of mycosis fungoi'des. Neu- 
mann 3 calls attention to the fact that these severe forms of iodide- 
eruption occur in patients suffering from albuminuria. 

The purpuric rash occurs in petechial macules, discrete and miliary, 
situated chiefly on the lower extremities. In a case reported by Mac- 
kenzie (quoted by Van Harlingen) a dose of 2-1- grains (0.166) taken 
by an infant was followed by a fatal result after petechiae appeared. 

Iodoform. — The internal administration, or the absorption through 
wounds, of this drug has been followed by macular, papular, vesicular, 
bullous, petechial, and mixed eruptions. Grave, and even fatal, 
systemic results are noted, including fever, delirium, emaciation, and 
nephritis. (For the local effects of the drug see Dermatitis Venenata.) 

1 Jour. Cutan. Dis., 1886, iv., p. 383. 2 Union med., 1882, xxx., p 481. 

3 Archiv, 1899, xlviii., p. 323. 



DERMATITIS MEDICAMENTOSA. 243 

Jaborandi and Pilocarpine are capable, when ingested, of inducing 
free diaphoresis ; erythematous macules, wheals, and pinhead-sizea 
papules have been seen upon the surface as a result. 

Mercury. — Mercury when ingested is reported to have produced an 
erythematous rash upon the surface of the skin. In view of the fact 
that the metal has been, in its various compounds, administered for so 
long a period of time and for so many various diseases, without the 
production of cutaneous symptoms, it is a fair hypothesis that in the 
few reported cases there was coincidence rather than causation. Mer- 
curials when applied to the external surface of the body are, as is well 
known, capable of exciting, in various degrees, cutaneous irritation and 
inflammation. 

Opium and its Alkaloids. — Erythema, wheals, and occasionally in- 
tense pruritus, with oedema, and subsequent desquamation, have fol- 
lowed the ingestion of opium and several of its alkaloids, notably 
morphine. In its mildest expression this cutaneous effect is limited to 
a characteristic itching about the nostrils that can be perceived in a 
large proportion of all patients as soon as the general effect of the 
opiate becomes apparent. In some patients there may follow an in- 
tense and distressing general pruritus without efflorescence, and it is 
certain that the subsequent urticarial efflorescence is caused by the free 
diaphoresis which the medicament induces. This fact is a matter 
of practical moment, as the use of an anodyne for the purpose of 
procuring sleep for a patient tormented with a nocturnal pruritus 
would seem to be occasionally indicated. Inasmuch as chloral, potas- 
sium bromide, and the opiates are all capable of aggravating such dis- 
tress, great caution is needful in such emergencies. In general, it may 
be said that the employment of these and similar remedies for the relief 
of pruritus should be interpreted as a confession of weakness on the 
part of the physician, who ought to be able to alleviate the distress of 
his patient by a judicious employment of topical remedies. 

Petroleum and its products are responsible for a large list of medic- 
mentous rashes (see Antipyrin, etc.). 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of a 
young girl who exhibited a pemphigoid rash after the ingestion of 
phosphoric acid. According to Farquharson, 1 phosphorus itself is oc- 
casionally responsible for purpura with gastro-intestinal derangement 
and jaundice preceding a fatal issue. 

Podophyllin. — Winterburn 2 reports that those who work in resinoid 
podophyllin are liable to suffer, as a consequence of this exposure, from 
a cutaneous disease of the scrotum. 

Potassium Chlorate. — Stelwagon and others report that papules and 
macules have followed the use of this remedy, administered in the form 
of tablets. 

Quinine, Cinchona, and Cinchona Alkaloids. — Morrow 3 collected the 
records of over sixty cases of quinine-exanthem, and he shows that 
its prevailing type is exanthematous, the rash being of a vivid 
hue, disappearing on pressure, and resembling scarlatina. Other 

1 Loc. cit. 

2 Louisville Med. News, 1882, xiii., p. 187. 

3 N. Y. Med. Jour., 1880, xxxi., p. 244. 



244 INFLAMMATIONS. 

lesions produced are wheals, papules, vesicles, petechia?, hemorrhagic 
purpura, bullae, and in one instance an intense localized dermatitis 
with beginning gangrene of the scrotum. In some of the cases the 
rash appears on repetition of the dose, and even after recourse to 
other alkaloids. The subjects are mostly women. As with most of 
the other exanthem-producing drugs, small doses suffice for the effect 
where the idiosyncrasy exists. The rash has been studied in an adult 
male, who, after taking 2 grains (0.133) of quinine sulphate for the 
first time in six years, exhibited an efflorescence (over the entire sur- 
face of the body) of discrete, finger-nail-sized, salmon- and pinkish- 
tinted, scarcely elevated patches, accompanied by moderate pruritus. 
A repetition of the dose was followed by a recurrence of the 
exanthem. 

In several cases desquamation is reported as resulting from the rash. 
As to the occurrence of the general symptoms recognized under the 
title " cinchonism " (tinnitus aurium, etc.), these may and may not 
accompany the lesions. Morrow makes the pertinent suggestion, in 
view of the frequent similarity of the rash to that exhibited in scarla- 
tina, that many cases hitherto recorded as recurrent attacks of that 
disease and measles, with other anomalous cutaneous eruptions, may 
have been instances of quinine-exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases in which these 
substances after ingestion produced cutaneous symptoms have been 
made by Heinlein, Wheeler, and Freudenberg, all cited by Van Har- 
lingen. The symptoms were diffused redness, urticarial lesions, vesi- 
cles, pustules, petechia?, and vibices, accompanied by intense pruritus 
and folloAved by desquamation. Engman 1 reports an interesting case, 
including the histology of the lesions. 

Salipyrin. — (Edema of the skin and actual loss of tissue have resulted 
from the administration of gramme doses of salipyrin to a man aged 
fifty-four years (Schmey). 

Santonin. — A generalized eruption of urticarial lesions seated upon 
a reddened surface and accompanied by oedema is reported by Sieve- 
king as occurring in a child to whom santonin had been administered 
as a vermifuge. 2 

Sodium Benzoate. — Rohe 3 reports two cases in which an erythema- 
tous rash, with well-defined border, accompanied by itching and slight 
desquamation, occurred during the use of sodium benzoate. The patients 
were a woman, aged thirty-five years, and a boy suffering from diph- 
theria. The eruption disappeared on discontinuance of the remedy, 
and was made successively to appear and disappear by its alternate use 
and disuse. 

Sodium Biborate. — Gowers 4 reports the occurrence, especially on the 
arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of sodium biborate. Some of the 
resulting patches were one and a half inches in diameter. Three cases 

1 Jour. Cutan. Dis., 1899, xvii., p. 555. 

2 Brit. Med. Jour., February 18, 1871. 

3 Maryland Med. Jour., 1881, viii., p. 91. 

4 Lancet, 1881, ii., p. 546. 



DERMATITIS MEDICAMENTOSA. 245 

in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. — Deschamps (cited by Duhring) reports an erythema- 
tous rash after the administration of the thorn-apple. 

Strychnine. — Skinner (cited by Van Harlingen) reports a case in 
which an eruption of six weeks' duration ensued upon the administra- 
tion of quinine and strychnine together ; the former in the dose of In- 
grains (0.10) the latter in the dose of ^ grain (0.0025). 

Sulphonal. — Diffuse macular and scarlatiniform eruptions are seen 
occasionally. Vesicular and purpuric lesions have also been reported. 

Tanacetum. — A case of varioliform eruption produced by the inges- 
tion of 1\ drachms (6.) of the oil of tansy, administered for abortifa- 
cient purposes, is reported by Potter. 1 There were antecedent clonic 
convulsions. The result was not fatal. 

Tar and Turpentine. — Erythematous, vesicular, and papular rashes 
are reported as resulting from the ingestion of these substances. 

The following medicaments may be added to the list of drugs 
capable of producing rashes when administered by the mouth : 

Anacardium, alcohol, bitter almonds, antimony, argenti nitras, benzol, 
chinolin, bitter-sweet, capsicum, cantharides, duboisin, ferrous iodide, 
guarana, kavakava, creosote, resin, castor-oil, ipecacuanha, hyoscyamus, 
lactophenin, matico, lead and its compounds, mesotan, sulphur and cal- 
cium sulphide, veratrum viride, cocaine, conium, pimpinella, rhubarb, 
tuberculin, and valerian. 

Many of these drugs have been effective in but few instances. There 
is no reason why the list should not in the future greatly be enlarged, 
as it is probable that every medicament is capable of producing a 
temporary efflorescence when the system exhibits a special sensitiveness 
to its action, the character of the eruption depending largely on indi- 
vidual idiosyncrasies, and on the circumstances (including the con- 
dition of the tissues) attending the administration of the drug. 

The Diagnosis of the various medicinal rashes described above does 
not, fortunately, demand a recognition of the essential peculiarities 
impressed upon each by the exciting cause, since in many cases such 
peculiarities do not exist. The same drug may, on the one hand, 
produce a rash with symptoms widely differing in a group of 
patients, while, on the other hand, the urticarial resulting from the 
ingestion of " head-cheese," quinine, and chloral may be indistin- 
guishable. But to establish the fact that a medicamentous eruption 
is present in any given case is a long step in the direction of reaching 
the precise cause that has been in that case effective. This informa- 
tion must often be obtained from the lips of the patient. The me- 
dicinal rashes are in general remarkable for their sudden appearance, 
their symmetry, their diffusion over large areas of integument, the 
presence of pruritus, the absence of fever, and their existence alike 
upon exposed and protected surfaces of the skin, thus hinting at the 
1 New England Med. Jour., October 15, 1881. 



246 INFLAMMATIONS. 

action of some cause not operating externally. Excluding syphilis 
and the exanthematous fevers, a generalized rash of sudden occurrence 
should always raise the suspicion of a dermatitis medicamentosa. 
Similarly in cases of preexisting cutaneous disease, syphilis, eczema, 
or psoriasis, the sudden occurrence of lesions of a new type widely 
diffused, or of rapid aggravation in situ, or of speedy extension in 
the area of those already in existence, should awaken the suspicion, 
if there be fever, of the exanthemata, and, without a febrile process, 
of the medicinal rashes. Thus, we have seen two patients with eczema 
exhibit rapid rise in body-temperature, and subsequently develop a 
generalized variolous rash ; and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or even long 
past the eruptive stage of that disease, showing their faces, necks, and 
shoulders covered with an acneiform rash produced by potassium 
iodide. The practitioner cannot too strongly be urged to view with 
exceeding watchfulness the skin of a patient affected with any of the 
common disorders (eczema, acne, and psoriasis) when the eruption 
becomes anomalous as to type, distribution, or symptoms. 

The medicamentous rashes, as a rule, disappear rapidly after the 
withdrawal of the exciting cause, and they require no further manage- 
ment. In some cases the soothing lotions, baths, and dusting-powders 
employed in the treatment of acute eczema may be required. 

It should not be forgotten that the patient who exhibits these lesions 
is usually one who has been suffering from the real or fancied disease 
for relief of which the drug was taken, and that condition may require 
recognition and management. 

In Morrow's treatise it is shown that the same drug may produce 
a variety of eruptive phenomena, and that the same eruptive features 
may result from the ingestion of different drugs. He points to what 
he concludes to be the neurotic origin of many of these rashes, and 
believes that the proof is inconclusive that they are to any considerable 
degree brought about by elimination, through the cutaneous glands, of 
the noxious element introduced with the drug. Tilden, however, calls 
attention to the fact that many of these eruptive phenomena are of the 
nature of angioneuroses, similar to Trousseau's tache c£r6brale, requiring 
often increase in the irritability of the cutaneous vessels, with exuda- 
tion of serum, outwandering of blood-cells, and, in case of hemorrhagic 
lesions, some change in the vascular w r alls themselves. 

FEIGNED ERUPTIONS 

Are usually varieties of dermatitis (erythematous, bullous, traumatic), 
discolorations, or ulcers produced by acids, caustics, and other chem- 
ical agents, or friction, for the purpose of exciting sympathy, extorting 
charity, securing hospital comforts, transportation to city life, etc. 
The persons employing these devices are, as a rule, criminals, hysterical 
young women, mendicants, soldiers, sailors, or servants seeking release 
from service. The extent to which hysterical women will go is well 
illustrated in one of the authors' cases, a young woman, who had 
suffered amputation of one finger and six months later asked to have 



X-RAY DERMATITIS. 



247 



the entire hand removed for a " gangrene/' which disappeared under 
a fixed dressing, and which she afterward confessed was due to 
applications of carbolic acid. The peculiarities, briefly, of these artifi- 
cial eruptions are : their odd appearance, not resembling the well-known 
types of ordinary disease ; their sharp definition, due to limitation 
of the disease to the area of contact of 
the article employed in its production ; Fig. 42. 

their occurrence on parts most accessible 
to the hands and the eyes of the sup- 
posed victim of the disease, being in 
right-handed persons most percepti- 
ble on the anterior portions of the body, 
particularly over the surface of the right 
thigh or leg, and over the left arm or 
shoulder ; evidence of drops where a 
caustic liquid has been spilled over the 
surface, or of angularity in outline, due, 
as a rule, to downward flow of a fluid 
from above ; and staining of the fingers 
or nails, or of the tissue beneath the 
latter, by the operator. In a suspected 
case the diagnosis may be made clear by 
covering the affected areas with a plaster 
or other fixed dressing, since the artifi- 
cial eruption quickly disappears when 
the patient is prevented from making 
the effective applications. 

Many cases of dermatitis gangre- 
nosa and erythema gangrenosum have Feigned eruption. 
proved to be produced artificially by the 

patients themselves. Other diseases have thus been imitated. Among 
them may be named : sycosis, favus, alopecia, ringworm, scabies, 
bromidrosis, hsematidrosis, chromidrosis, erysipelas, abscess, and 
syphilis. 

X-RAY DERMATITIS. 

The symptomatology, etiology, and pathology of ic-ray dermatitis 
are considered under Radiotherapy, page 114. 

Treatment. — A better understanding of the possibilities of the 
a>rays has developed a technique, the careful following of which should 
prevent severe #-ray burns, except in rare instances where it is thought 
advisable to risk the danger of such a burn for the sake of quickly 
destroying a rapidly progressing malignant growth. Even the mild 
forms of a>ray dermatitis can usually be avoided by the exercise of 
proper skill and care. 

The simpler forms of dermatitis due to arrays may often be treated 
successfully with the measures recommended for corresponding phases 
of eczema and dermatitis due to other external causes. Frequently, 
however, even a mild dermatitis due to #-rays is persistent and exceed- 
ingly painful, and not infrequently is aggravated rather than relieved 




248 INFLAMMATIONS. 

by measures applicable to corresponding grades of dermatitis from 
other causes. In such cases various applications with or without 
some local anodyne may be tried. Among those we have found the 
most useful are the following : The lead and opium wash with or with- 
out the addition of a powder, glycerin, or boric acid, as recommended 
for the treatment of acute eczema ; a mixture of equal parts of this 
lotion and carron oil (made with olive oil) ; compound stearate of zinc 
powder ; a simple ointment containing one or two drachms of orthoform 
to the ounce. We have found the following paste, recommended by 
Engmann, 1 very satisfactory : 

"Boric acid, 12 drachms (48.); zinc oxide, starch, bismuth sub- 
nitrate, and oleum olivse, of each 1 ounce (30.) ; liquor calcis and lano- 
line, of each 3 ounces (90.) ; rose water, 12 drachms (48.). The powder 
should be well rubbed up in a mortar, the lanolin e added ; the olive oil 
and liquor calcis then are mixed and slowly added ; when this is 
mixed thoroughly the rose water is added, and the whole beaten up in 
the mortar into a light, creamy paste." 

The surface should be kept covered with this paste, spread on old 
linen or several thicknesses of gauze. A sheet of gutta-percha tissue 
may be placed over the dressing to prevent evaporation, unless this 
is uncomfortable, as it sometimes is, to the patient. 

In deep-seated ulcers, which fortunately are seen but rarely, the 
treatment is usually surgical, the necrosed tissue having to be removed 
and the surface covered with skin-grafts. 

DERMATITIS GANGRENOSA (SPHACELODERMA). 

Gangrene of the skin may result from a dermatitis originally due to 
the action of either excessive cold or heat ; to the action of externally 
applied chemical agents (caustics, strong acids, alkalies, etc.) ; or to 
shock ; to ergot and other substances ingested ; to infectious diseases 
(lepra, tuberculosis, syphilis, erysipelas) ; to central nervous disease 
(decubitus, Raynaud's disease) ; to disorders of the blood-vessels (embol- 
ism, thrombosis, acute and chronic endarteritis obliterans, calcareous 
changes in the arterial vascular tunics) ; to compression of vessels by 
ligature, by tumors, or by inflammatory products. 

Multiple Gangrene of the Skin is reported as complicating 
typhoid fever (Hahl 3 ) and malaria (Osier 4 ). It occurs also in other 
disturbances. Hartzell 5 and others 6 report cases in which the lesions 
were apparently auto-inoculable, and in which bacilli and cocci were 
demonstrated. The condition is due probably to local infection of 
tissues having diminished power of resistance. 

1 Brit. Jour. Derm., 1903, xv., p. 390. 

2 See Dermatitis Venenata. 

3 Amer. Jour. Med. Soc., 1900, p. 251. 

4 Johns Hopkins Hosp. Bull., 1900, p. 41. 

5 Amer. Jour. Med. Sci., July, 1898. 

6 Sailer, Amer. Jour. Med. Sci., 1902, cxxiii., p. 59 ; and Bernard and Jacob, Arch. 
Med. exp. et d'Anat. path., 1903. 



DERMATITIS GANGRENOSA. 249 

Crocker describes two cases, one that of a male, the other that of a 
female patient, in whom, as a consequence of scarlatina or some poorly 
defined antecedent disorder, crops of pustules, followed by gangrenous 
sloughing, occurred in almost all parts of the body, one attack rapidly 
following another with rise of body-temperature. A pustulo-crusta- 
ceous lesion of the upper eyelids, with gangrene resulting in a small 
circular ulcer, is reported as occurring in two healthy children. 

Fournier describes " spontaneous gangrene of the penis " following 
pruriginous and other papules of the part which were scratched and irri- 
tated. The gangrenous change in this condition succeeds a dull-reddish 
congestion of the part, including the mucous surface of the glans, fol- 
lowed by vesiculation, enormous tumefaction, and often by lymphan- 
gitis and erysipelas. 

The disorder is seen not infrequently in hysterical women, the 
affected plaques being irregular in outline and superficial or deep. 
After the slough has separated the plaques usually cicatrize without 
serious mischief resulting. Occasionally they spread as serpiginous 
lesions over the surface. Though doubt has been cast on these cases, 
in consequence of the discovery among them of feigned disease, it is 
certain that the malady occurs as described, without the operation of 
external agencies. These cases are included in those described else- 
where as erythema gangrenosum. In making a diagnosis the feigned 
eruptions and their distinctive features should be kept in mind. 1 

Diabetic Gangrene has been described by Kaposi as occurring on 
the limbs of patients affected with glycosuria. Bullae appear, dry in the 
centre, and form black crusts, while new bulla? arise at the periphery, 
thus producing a serpiginously spreading area with vesicular border, 
resulting in both dry and moist gangrene of the central parts. Similar 
cases are described by other writers ; in a few instances large portions 
of an extremity have been destroyed. Gangrene of fingers and toes 
without bullae is reported. The association of gangrene with diabetes 
is due probably to the fact that the tissues of diabetic individuals 
furnish a good medium for the growth of certain bacteria. 

Dermatitis Gangrenosa Infantum 2 (Multiple Dissemi- 
nated Gangrene of the Skin in Infants, Varicella Gan- 
grenosa, Pemphigus Gangrenosus, Rupia Escharotica, Gan- 
grenous Infantile Ecthyma, Ecthyma terebrans). — As a 
consequence of the exanthemata (variola, varicella, rubeola, purpura, 
erythema nodosum) the head, shoulders, and trunk of some children 
exhibit crust-covered lesions which ulcerate and finally throw off a 
gangrenous, split-pea- to small-coin-sized, deep or shallow slough, after 
which repair commonly occurs. Severe losses are produced by a 
species of coalescence of smaller ulcers. 

1 Cf. Van Harlingen, " The Hysterical Neuroses of the Skin," Amer. Jour. Med. 
Sci., 1897, cxiv., p. 64, and Jour. Cutan. Dis., xxi., p. 403, the two papers giving com- 
plete bibliography ; Wende, Jour. Cutan. Dis., 1900, xviii., p. 548 ; and Bronson, Ibid., 
1903, xxi., p. 456. 

2 Cf. Veillon and Halle, Annales, 1901, ii., p. 402 (with review of literature). 



250 



INF LA MM A TIONS. 



These gangrenous points may occur beneath some previously exist- 
ing lesion or crust, or they may at the outset be spontaneous. In most 
cases there forms a vesicular lesion with rosy areola, that speedily 
bursts, leaving a blackish slough about which a circle of eliminating 
inflammation spreads. Thromboses result in the blood-vessels of the 
neighboring parts, oedema follows, and there is excited a train of re- 
active symptoms — fever, vomiting, diarrhoea, albuminuria, cardiac or 
pulmonary troubles. The patient becomes greatly emaciated. Crocker 
reports hemorrhagic vesicles and bullae in grave cases. 



Fig. 43. 









k- • ' # 


■ m 




'ma 







Dermatitis gangrenosa infantum. 

Brocq is careful to distinguish between these grave forms of disease 
and those to which should be denied the appellation dermatitis gan- 
graenosa. In these milder forms vesicular lesions may develop, simu- 
lating those of varicella, occurring perhaps in crops and accompanied 
by a mild fever. Some among them may be covered with a blackish 
crust, may indurate at the base, surround themselves with an angry 
zone of inflammation, and, especially about the trunk, the thighs, and 
the anogenital region, ulcerate beneath the crust. Even though these 
ulcers coalesce and acquire a grave aspect, the result, as a rule, is not 
unfavorable. 

The subjects of this affection are infants and young children, from 
three months to several years of age. Beside the exanthemata which 
may precede, cases are on record as following tuberculosis, rickets, and 
syphilis. The process is one which, originally dependent upon the 
toxic effects of specific cocci, evidently requires a special soil for its 
effective operation. 

The treatment should include support of the general system, with 
local antisepsis by the aid of boric-acid solutions, aristol, iodol, and 
the dressing of the parts Avhich slough by the usual deodorizing agents. 

The prognosis is at times grave. 



ERYSIPELAS. 251 

SYMMETRICAL GANGRENE OF THE EXTREMITIES 
(LOCAL ASPHYXIA, RAYNAUD'S DISEASE). 1 

This affection usually is announced first by the common signs of 
arrest of circulation in the capillaries, numbness, loss of sensibility, 
and pallor or the color of passive congestion (local asphyxia, digiti 
mortui) in fingers and toes exposed to extremes of cold or heat. The 
face, nose, ears, brows, and other regions and organs may also be in- 
volved. Eventually subjective sensations are awakened, stinging 
and lancinating pains, pricking and crawling sensations. The parts 
involved, often the second and third phalanges of the digits, first 
become livid, then cold, firm, and black ; and gangrene of more or less 
of the affected tissue results, usually presenting the dry aspect. Bullae 
may form along the line of demarcation. Separation of the gangrenous 
portions usually takes place slowly. The entire process may require 
but a few days or several weeks for its completion. 

Variations occur in a singular thinning of the digits, which may 
become indurated and slender ; or they may be covered with small 
whitish cicatrices where a superficial slough has separated ; or the 
parts may become cool, white like alabaster, and recover their tone 
without loss of tissue ; the nails alone may fall ; or indeed the entire 
process may meet with arrest in the early stage of blueness and asphyx- 
iation of the extremities. The mild forms which terminate in recovery 
may recur, and the type may become with each recurrence more severe 
until finally gangrene results. 

Etiology and Pathology. — This disease occurs equally in the two 
sexes and at all ages, and often in the cold weather of the winter 
season. There is a growing suspicion that many cases are of syphilitic 
origin, as the disease has followed specific infection. It has also suc- 
ceeded tuberculosis, diphtheria, the exanthemata, diabetes, and hemo- 
globinuria. It is apparently due to trophic disturbances, the exact 
nature of which has not been determined. By means of the arrays 
Beck 2 demonstrated in two cases atrophic and other changes in the 
bones. 

Treatment is by employment of the galvanic current, stimulation 
(as in dermatitis with congelation), and friction with stimulating alco- 
holic, camphorated, or oleaginous lotions. It is desirable to apply both 
electricity and (in some cases) dry cupping over the spinal region. 
Systemic treatment should be adapted to the underlying condition in 
each case. 

The Prognosis is in some cases grave ; when the morbid condition 
is limited to a small part of the body recovery is often satisfactory. 

1 For bibliography, see monograph by Monro, Glasgow, 1899, and chapter by S£e, 
La Pratique Dermatologique, vol. i., p. 436. 

2 Amer. Jour. Med. Sci., 1901. 



252 INFLAMMATIONS. 

ERYSIPELAS. 

(Gr. epvOpog, red; Tvella, the skin.) 

(St. Anthony's Fire. Ger., Kothlauf, Erysipel ; 
Fr., Erysipele, La Kose.) 

Symptoms. — This disease is usually preceded by a prodromic 
period of malaise (lasting for twenty-four hours or less), which may be 
ushered in by one or several chills followed by febrile symptoms. The 
latter are accompanied by anorexia and often by vomiting with general 
depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first noticed 
in a nut- or egg-sized patch, the integument of which is tumid, 
slightly elevated, irregular in contour, distinctly circumscribed, and 
presents a rosy or crimson-reddish color with a peculiarly smooth and 
characteristic shining or glazed appearance. The sensations awakened 
may be those of moderate pruritus, of pain, heat, or burning. To the 
touch the affected part is tender, moderately firm, and perceptibly 
hotter than normal. The color fades under pressure to a yellowish 
white. 

In typical cases the erysipelatous blush and swelling spread over 
an area which may be of the size of the palm, or may even cover 
ihe surface of an entire limb or a region of the body. In cases of 
moderate grade the inflammation attains a maximum of extent and 
severity within a week, remains apparently unaltered for a day or more, 
and then begins to abate, with amelioration of all the concomitant 
symptoms. The fever, which often precedes the eruption, continues 
unabated during its progress, the temperature rising to 105° or 106° F., 
with nocturnal exacerbation, cephalic and lumbar pain, dryness of the 
tongue, gastric distress, and occasional delirium. As involution of the 
disorder is accomplished the redness is replaced by the brownish, 
bluish-red, and dirty-white shades often seen after the disappearance 
of erythema multiforme, the epidermis finally desquamating in various 
degrees according to the extent of the preceding inflammation. 

In other cases, in which the exudation of serum beneath the epi- 
dermis has been rapid, the epidermis is raised in the form of vesicles, 
pustules, or bullae, more often the latter, and precisely as in the severe 
forms of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. This 
complication is particularly liable to follow the disorder when it attacks 
the seat of surgical wounds and injuries. 

The febrile symptoms are, throughout, persistent and characteristic 
of a specific toxaemia. The body-temperature, as has been seen, may 
reach 105° to 107° F., with vespertine exacerbations and remissions; 
it may also become subnormal. If not relieved in the course of seven 
or eight days, complications may be expected, namely, oedema, abscess, 
phlegmonous inflammation, gangrene, or inflammatory accidents involv- 
ing the membranes of the brain, lungs, heart, bowels, kidneys, perito- 
neum, or joints. 



ERYSIPELAS. 253 

Erysipelas Ambulans is a term used to describe that form of the 
affection in which the erysipelatous blush, after involving a given area, 
spreads with greater or less rapidity to the parts in the vicinage, either 
by direct extension and uniform advancement in one direction of the 
tumid and distinctly circumscribed border, or by linear, digital, or irreg- 
ular prolongations radiating from the inflammatory focus. As the 
blush and swelling advance in one direction there is usually a corre- 
spondingly rapid disappearance on the other. At other times the disease, 
while extending to a new area and abandoning the old, is relighted in 
the latter, and thus an irregularly involved and irregularly extending 
erysipelatous surface presents for weeks the varying phenomena of the 
disease. In yet other cases, chiefly those in which there has been a 
history of traumatism, a long erysipelatous linear streak or band may 
spread from the site of the traumatism in one direction or another, sug- 
gesting the indurated lines observed in lymphangitis. In severe cases 
the febrile, nervous, and other symptoms are grave, including coma, 
delirium, meningitis, and the signs of serious involvement of the lungs, 
pericardium, pleura, and bowels. Metastatic abscesses may also occur 
in the cutaneous and subcutaneous tissues, the joints, the peritoneal 
cavity, and even in the viscera. Death may result from these complica- 
tions, or from shock, exhaustion, or pyaemia. 

Surgical accidents aside, the face is the commonest seat of the dis- 
ease, on which the disease may be first seen upon one side of the nose, 
a cheek, a lip, or an eyelid. It often attacks the lobe of the ear after 
the operation of piercing the lobule for the insertion of ear-rings in 
women ; thence it may extend over the whole face, inclusive of the 
mucous linings of the mouth and the nose, that present a dry, tumid 
and glazed appearance, suggestive of the symptoms displayed upon the 
skin. The inflammation may extend to the hairy parts, but in many 
cases it exhibits a species of reluctance to transgress the limits there 
presented. It may be noticed in cases of mild grade, in which no appli- 
cations have been made to arrest a local progress, that the elevated 
border spreads symmetrically to within a few lines of the male beard 
or the hairs at the edge of the forehead, and there is arrested. In 
severer grades these limits are surpassed, and then, as a rule, the 
extension is rapid and formidable. In this way the entire head may 
■become enormously swollen, suggesting to a casual observer that it 
is twice its normal size. The patient then is greatly disfigured ; 
his scarlet lips are swollen and parted, permitting the escape of 
saliva ; the ears, as usual when greatly enlarged, project in a marked 
degree from the side of the head ; the eyelids are oedematous and 
incapable of separation ; the face is disfigured by bullae or crusts ; and 
the mind disordered in the violence of the fever or the accesses of 
delirium. When recovery ensues the hairs generally fall. 

All regions of the body may be invaded, such as the vaccinated 
arm, the leg the skin of which is involved in venous varicosities, 
the scrotum or the umbilicus of the infant, the genitalia of the newly 
delivered woman, the breast of the nursing-mother, and every surface 
which has been the seat of punctured, incised, contused, or poisoned 
wounds, or other accidents of the integument to which the germs of the 
disease may have had access. 



254 INFLAMMATIONS. 

Cheonic Eeysipelas. — Habitually recurrent and indolent erysip- 
elatous attacks, the identity of which with the disease here described 
it is difficult to establish, occur frequently. Some of these cases are 
due probably to repeated infection with bacteria which may be attenu- 
ated or less virulent forms of the cocci found in the severe types of 
erysipelas. Many cases, however, reported as " chronic or recurring 
erysipelas" are instances of eczema, dermatitis, or rosacea which are 
subject to acute exacerbations. Instances occur in w T hich the face, 
wholly or in part, is the seat of a low grade of inflammation with local 
heat, swelling, redness, considerable infiltration, and some tenderness, 
the skin being irritable and worse after exposure to a high wind or 
after excesses at the table. But most of such cases fail to exhibit the 
distinct imprint of erysipelas ; they are not only chronic in course, but 
are also exceedingly indolent, often lasting for years ; they are unaccom- 
panied by fever ; they distinctly are limited in all accesses of aggra- 
vation to the same part of the face ; they are characterized rarely by a 
bullous efflorescence ; many occur in the subjects of chronic alcoholism ; 
and the specific germs of erysipelas are not present. 

Etiology. — Erysipelas is caused by the streptococci of Fehleisen, 
or other organisms, which gain admission to the tissues through some 
lesion of the surface. The site of infection may be a surgical or other 
wound, or it may be a slight scratch or an unrecognized abrasion of the 
skin or mucous membrane. 

In the face, catarrhal and ulcerative processes involving the mucous 
membrane of the mouth, ears, and nose are often the cause of erysip- 
elas, these processes occurring in a wide range of disorders from syph- 
ilis of the nasal bones to caries of the teeth. Tuberculous and other 
ulcers, as well as eczema and several skin-diseases, frequently furnish 
a means of ingress to the streptococci. Injuries of, and surgical opera- 
tions upon, the scalp not conducted with antiseptic precautions, and 
the common piercing of the lobe of the ear in women and female 
children for the insertion of ear-rings, may be followed by the appear- 
ance of the disease upon the scalp, as a result of which the hair often 
falls. Fistules, vaccination, lesions of the tender umbilicus of the 
newborn infant^ and railway accidents may be named as common causes 
of the disease in other regions. 

Predisposing causes of this disease are to be sought for in cachexia, 
general debility, alcoholism, kidney-disease, epidemic influences, trau- 
matism, violation of hygienic rules, idiosyncrasy, and occasionally the 
recurrence of previous attacks. 

Jordon x and others have demonstrated apparently that the disease, 
both mild and severe forms, may be produced by staphylococci as well 
as by streptococci. Jordon has shown that typical erysipelas may be 
produced in the rabbit by a number of different cocci. ^ 

Pathological Anatomy. — The disease is an acute inflammation of 

the skin and of the subcutaneous tissue. Unna, whose examinations 

were made largely in the skin of children and infants, found invariably 

a simultaneous invasion of both the cutis and the hypoderm in ery- 

1 Munch, med. Wchnschrft, 1901, p. 1371. 



ERYSIPELAS. 255 

sipelas, the former recovering far more rapidly than the latter, and 
rarely reaching such a grade of activity. The venous capillaries were 
all enormously distended, as if paralyzed by the poison present, and the 
collateral lymphatics with the lymph-spaces were equally dilated. All 
the cutaneous vessels swarmed with streptococci, both in the central 
and the marginal zones. 

Diagnosis. — Erysipelas is to be distinguished from the erythemata, 
from dermatitis of various grades, from eczema, and from scarlatina. 
As a rule, its recognition is readily effected w T hen the presence of 
the fever in erysipelas is kept in view, as also the peculiar shining, 
swollen, and rosy-reddish to damask hue of the affected parts. The 
redness is never produced, as in scarlatina, by multiplicity of reddish 
puncta, nor is it so widely diffused as in that disease. Erysipelas may 
at times be accompanied by a pruritic sensation, but the patch which it 
affects is never by any possibility scratched. By this simple test alone 
one may often distinguish an erysipelas of the face from an eczema of 
the same region in a child. From a chronic dermatitis with thicken- 
ing of the affected tissues and redness of the surface, erysipelas is to be 
distinguished by its tendency to spread, by its acute course, by its fre- 
quent association with bullous or vesicular lesions, and by the color, 
outline, and raised border of the affected patch. However, it must be 
understood that to these localized patches of chronic dermatitis several 
authors have given the name "chronic erysipelas," the difference 
between the views held on this point being chiefly one of titles. 

Treatment. — The method of treating erysipelas by the administra- 
tion of the tincture of iron internally has long been popular among 
American practitioners, but its efficiency is questionable. This prep- 
aration is given in full doses, from 10 to 50 drops, day and night every 
two to three hours, irrespective of the febrile state. 

The constitutional treatment is important, but is solely symptomatic, 
and should be directed to lowering the temperature, to obtaining proper 
functional activity of all the organs of the body, and in prolonged 
cases to sustaining the strength of the patient. Locally, when the 
erysipelatous blush has a distinctly circumscribed outline, an annular 
zone extending for an inch or more in width upon the sound and 
affected skin may be either covered with tincture of iodine, or be 
pencilled with a crayon of argentic nitrate, or be painted with a saturated 
solution of the same salt. Fraser * uses pure carbolic acid. As soon 
as the skin becomes white it is mopped with absolute alcohol. The 
purpose of such treatment is to limit extension of the disease. 
It is true that these measures will not always succeed, but it is 
erroneous to assert with some authors that they always fail. Certain 
it is that, whether effective or not in the production of the result, the 
advancing border of the disease will often fail to surpass the limits thus 
artificially described. Collodion has been employed for a similar pur- 
pose, and Darlin 2 advocated the revival of this method of treating the 
disorder, basing its claim on the fact that the dressing diminishes the 
temperature of the part thus protected, and that, by the compression 

1 Brit. Med. Jour., 1901. 

2 Bull. gen. de The>., 1881, vol. ii., p. 239. 



256 INFLAMMATIONS. 

excited, it interferes with septic absorption. Heppel l recommends the 
painting over the surface of a 10 per cent, solution of carbolic acid in 
alcohol, as an abortive treatment, for which Braithwaite 2 substitutes a 
solution of tannin of the same strength. 

Good results have been reached in the local treatment of erysipelas, 
first by attempting to limit the extension of the disease by the applica- 
tion of the tincture of iodine over the peripheral zone, and, secondly, 
by retaining over the entire surface affected neatly applied compresses 
saturated with a solution of sodium hyposulphite in the strength of 
about 1 drachm (4.) to the ounce (32.), or with 95 per cent, alcohol. 

Attempts to limit extension of the disease by local applications 
of an irritating sort (corrosive sublimate, silver nitrate, carbolic acid, 
tar, turpentine, etc.) are sometimes positively injurious. Dry heat 
applied by the aid of cotton or wool, cold compresses, or iced lead- 
lotions with intermissions of application, salicylic acid, boric acid, iodol, 
resorcin in solution, or iodoform in powder may be used. A 95 per 
cent, alcohol or a saturated solution of boric acid often gives good 
results if painted frequently over and for an inch or more beyond the 
affected area, or if applied on compresses. 

Koch applies 1 part of creolin, 4 of iodoform, and 10 of lanolin, cov- 
ered with gutta-percha. Nussbaum uses ichthyol and collodion, or equal 
parts of ichthyol and vaselin covered with a 10 per cent, salicylic lint. 
Hallopeau praises 1 part to 20 of sodic salicylate in aqueous lotions 
upon folds of linen. Elliott and others strongly recommend ichthyol 
in lotions, in oils, or in ointments. It may be used in strength vary- 
ing from 10 to 50 per cent., and is kept constantly applied to the 
affected area and for some distance beyond it. Tabit claims to abort 
the disease with a 10 per cent, solution of iodol in collodion. Injections 
of antistreptococcic serum have been used with varying success. 

Erysipelas rarely attacks a patient in vigorous health. The large 
majority of all the subjects of the disease are either those who have 
previously suffered from manifest general ill-health, or who have been 
complaining of local ailments, trifling wounds, nasal catarrh, or surgical 
accidents. It is these precedent conditions which often demand special 
attention. 

It is needless to add that all surgical indications are to be fully met 
when they are present : pus is to be evacuated, crusts removed, and 
drainage secured. The physician and surgeon alike should never for- 
get that the disease is infectious ; that the patient is to be isolated and 
to be supplied with an abundance of pure air ; and that fomites, surg- 
ical instruments, and even the non-disinfected hands of attendants are 
capable of transmitting the disease. 

Finally, there are forms of erysipelas which are remediless ; they 
are usually septic in character. The scarlet blush spreading from an 
irreparable injury of long duration is often the last protest of Nature 
against the damage which even her final resort of gangrene will not 
avail to repair. 

Prognosis. — Under favorable circumstances erysipelas, even of 

1 Arch, of Derm., April, 1881. 

2 Brit. Med. Jour., April, 1881, 



ERYSIPELAS. 257 

severe grade and extensive invasion, terminates in complete resolution. 
Reserve should be made, however, in every case, as a serious compli- 
cation has often transformed the simplest into the gravest form of the 
disease. The very young, the cachectic, the victims of drink, the 
aged, the inmates of hospital-wards depressed by other illness, and 
those mentally distressed by destitution and neglect, are particularly 
liable to suffer from grave and fatal forms of the malady. 

The patients who fill the beds in most lying-in hospitals are young 
women, either unmarried or deserted by their husbands, and unpro- 
vided with the necessities of life by those upon whom such a respon- 
sibility rests. The mental depression thus originating in connection 
with septicemic influences is responsible for much of the relation 
which erysipelas often seems to sustain to the puerperal state, as also 
for the appalling mortality which it may exhibit under these circum- 
stances. 

ERYSIPELOID. 

(Erysipelas Chronicum, Progressive Phlegmon, Erythema 

Migrans.) 

This term is employed by Rosenbach l to designate a special inflam- 
mation of the integument occurring as a complication chiefly of trau- 
matisms. When a wound is infected with the special poison of the 
disease a peripherally spreading tumid and empurpled halo encircles 
the site of infection, which slowly disappears in the part originally at- 
tacked while it extends progressively to another area. The advancing 
border of the disease is distinctly circumscribed, and may be festooned 
or scalloped. New points may appear from which the violaceous red- 
ness spreads, while others are in a state of apparent inactivity. 
This affection may be complicated with furunculosis, but scaling is said 
never to occur. Itching and burning sensations are usually present. 

Rosenbach believes that the source of this disease is a micro-organ- 
ism of the order Cladothrix, existing in putrid flesh and cheese, from 
pure cultures of which organism he is reported to have induced the 
disease. His position, however, is unfortified by experiments of other 
observers. 

The disease affects chiefly the fingers and hand (according to Elliott, 
also the scratched toes) of scullions, meat-dressers, fish-dealers, poul- 
try-cleaners, and persons of similar occupations. The distinction be- 
tween this disorder and erysipelas is based chiefly on the indolence of 
the former, its more superficial involvement of the skin, and the absence 
of constitutional symptoms. It is to be carefully distinguished from 
Crocker's " dermatitis repens " (some instances of which may be here 
included), from erythema multiforme, from erythema iris, and from 
ringworm of the hands. 

Treatment is efficient with local application of formalin, ichthyol, 
resorcin, pyoktanin-blue, pyrogallol, potassic permanganate, or the mer- 
curials in salves or in lotions. 

17 



V 



258 INFLAMMATIONS. 

FURUNCULUS. 1 

(Lat. furunculus, a petty knave.) 

(Furuncle, Boils. Ft., Furoncle, Clou ; Ger., Furunkel, Blut 

GESCHWAR, ElTERBEULE, ElTERGESCHWAR.) 

Furunculosis is characterized by the occurrence of one or more cir 
curnscribed cutaneous or subcutaneous abscesses, called " furuncles 
which usually terminate by necrosis of tissue in the centre of the 
phlegmon, the expulsion of the necrotic mass in the form of pus or a 
core, and a resulting cicatrix. 

Symptoms. — Furuncles commonly begin as tender and painful 
indurations in the skin or its subjacent tissues, the summit of each 
nodule soon becoming visible in the epidermis as a reddish punctum. 
A furuncle is the result of an active inflammatory process, limited to 
a definite area, and of greatest intensity at the centre of the involved 
mass. This centre is often represented by a hair-follicle, the pustule 
that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface or fairly im- 
bedded within or beneath the derma. A yellowish point in the centre 
of the erythematous swelling soon announces the occurrence of suppu- 
ration. When accidentally or artificially opened at this summit exit 
is given to thick yellowish pus with which blood may be commingled 
from the traumatism of neighboring capillaries. The small abscess 
may then, after discharging for a few days its purulent contents, grad- 
ually close by granulation, or may also expel from its cavity a tenacious, 
pus-covered, yellowish-green slough, known as the " core." This evac- 
uation is usually followed by relief of the tense and throbbing pain 
which is the well-known subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process varies 
with the extent of tissue involved, from a few days to several weeks. 
Boils may occur in any part of the body, but are most common about 
the face, the auricular region, the neck, the armpits, the anogenital 
surfaces, the hips, the buttocks, the breast, and the extremities. They 
may occur as single or as multiple lesions, or they may succeed each 
other in crops, especially about the buttocks, trunk, and thighs, for a 
period of several months. It is this succession of boils to which the 
term " furunculosis " is specially applied. The disease of the skin, in 
patients suffering from furunculosis, may produce a constitutional effect 
manifested in pyrexia, which is usually encountered only in individuals 
of irritable constitution when the furuncles are few and short-lived. 
There is also a decided chloro-ansemia due to the pain, fever, purulent 
drain, irritability of nervous centres, inappetence, and consequent per- 
version of nutrition. 

The sequels of boils are maculations of a violaceous tint, often per- 
ceptible in the skin for weeks and even months after their disappear- 
ance ; and pinhead- to penny-sized cicatrices which are permanent. 

f. Chirurg., 1887, xvi., p. 75. 






FURUNCULUS. 259 

Etiology. — The microbe which is the immediate cause of boils is 
usually, if not always, Staphylococcus pyogenes aureus/ though other 
pus-producing cooci also are found in the lesions. The remote cause 
is often exceedingly obscure. It is true that boils are encountered in 
typical subjects of diabetes, of the exanthemata, and of " hospitalism," 
in whom ansemia, asthenia, marasmus, malnutrition, and exhaustion 
resulting from excesses, from grave general disease, from low fevers, 
and from nervous strain, play a prominent part. But the reverse is 
also true. 

Scratching, eczema, scabies, other cutaneous diseases, lice, and ex- 
ternal irritants of various sorts are responsible for many boils, especially 
those that are few and not followed by similar lesions. When, how- 
ever, such sequence occurs it should not be forgotten that the pus is 
auto-inoculable, and that furuncles, if sufficiently numerous and large, 
are capable of disturbing the general economy. A collar-button at the 
back of the neck ; the edges of an unyielding corset in one unaccus- 
tomed to it ; a hard bench ; a saddle-tree ; a velvet coat-collar sheltering 
the germs responsible for a previous attack ; and many similar articles 
may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. g., by dyers, lead-manufacturers, etc. 

Lastly, it is exceedingly common for patients thus affected to apply 
to practitioners for remedies intended to "purify the blood"; and, in- 
asmuch as potassium iodide is often prescribed in response to this 
demand, the original trouble is thus enhanced to a manifold extent. 
Many cases of furunculosis are instances of boils resulting originally 
from external irritation, that have greatly multiplied and finally pro- 
foundly affected the system under the impulse of the so-called " blood- 
purifying" process. 

Pathology. — According to Unna, most furuncles begin with an 
impetiginous lesion due to the inoculation of the piio-sebaceous follicle 
with pus-cocci, the organism being, in the majority if not all instances, 
Staphylococcus pyogenes aureus. The cocci penetrate deeply into the 
follicle, into ramifications of the sebaceous gland, and into the sur- 
rounding tissue. An abscess thus is produced surrounding the follicle, 
which undergoes a necrosis en masse, producing the characteristic central 
core or slough. It is probable that in some instances the cocci are 
carried along the lymph-vessels to form abscesses about the neigh- 
boring follicles and glands. The lanugo hair-follicles are affected much 
more frequently than those of the stronger hairs. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
aggravated symptoms of the latter. Circumscribed furuncular ab- 
scesses of the groins and the axilla? are not to be confounded with 
suppurating, sympathetic, or virulent buboes of these regions, associ- 
ated with genital or extragenital contagious venereal sores. Errors 
of this sort have been made. Furuncles of the anal and genital regions 
in point of diagnosis may be significant of surgical affections of the 
1 Of. Gilchrist, Johns Hopkins Hosp. Eeports, 1903, xiv. 



260 INFLAMMATIONS. 

neighboring parts (perineal, periprostatic, peri-urethral, and scrotal 
abscesses in men ; suppuration of the vulvo-vaginal gland in women, 
etc.). 

Treatment. — The debilitated constitution of many patients affected 
with boils indicates clearly the need of a tonic regimen, including the 
administration of iron, quinine, and strychnine, the mineral acids, and, 
contrary to the generally accepted opinion of the laity, a generous diet 
of milk, cream, eggs, and fresh meats. To these articles of diet wines 
and malt liquors may at times be added with advantage. Change of 
climate, of diet, of cooks, and of the habits of life is most serviceable in 
cases of prolonged furunculosis. The mineral waters at some health 
resorts prove especially valuable for the debility which often results 
from these disorders. The urine should always be examined for sugar, 
albumin, and an excess of urates. The internal remedies which possess 
reputation in this complaint are arsenic, sulphur and the sodic sulphites, 
the alkalies, tar, fresh yeast in tablespoonful doses, phosphorus, and the 
syrup of the hypophosphites of calcium, iron, sodium, and potassium. 

Calcium sulphide, which was once more highly esteemed than any 
other of the internal remedies named, is given in doses of ^ to in- 
grain (0.0066-0.0133) every three or four hours. It is doubt- 
ful whether the drug exerts any influence whatever upon furuncles. 
In lithaemia potassium acetate or citrate is given in large dilution, 
or the liquor potassse ; in gouty states colchicum, salol, and the 
alkalies, including the sodic salicylate. No one of these articles, how- 
ever, may be described as an efficient and certain remedy for the com- 
plaint ; many eases will progress without hindrance from any or all 
of them. Fresh brewer's yeast, recommended by Lowenberg, Crocker, 
Brocq, 1 Desfosses, 2 and others is sometimes of service. A tablespoon- 
ful or less may be given three times a day. 

Attempts in the direction of aborting a furuncle by the topical 
application of the stronger alkalies (aqua ammonise) or acids, caustics, 
cautery, ice, iodine, or carbolic acid, or premature complete excision 
with the scalpel, occasionally succeed, but often they fail. Boils may 
be aborted at times by the injection beneath the lesions of from 3 to 6 
drops of a 3 per cent, solution of carbolic acid. 

The objects of local treatment are to reduce the inflammatory 
process, allow the free escape of pus, and to prevent infection of other 
follicles in the neighborhood. The surface of the boil and the skin in the 
neighborhood should be kept thoroughly clean by frequent use of hot 
water and greeji soap, and the application at least twice daily of some 
simple antiseptic solution, such as 50 per cent, alcohol, 1 per cent, car- 
bolic acid lotion, or weak bichloride solution. Stelwagon 3 recom- 
mends for the purpose : 



R Resorcin, gr. xv-xxx ; 1-2 

Acidi borici, .^jss ; t) 

Alcoholis, f|j ; 30 

Aquae dest, f$v ; 150 

1 La Presse med., 1899, lxi., p. 45 (with bibliography). 

2 Ibid., 1892, liv., p. 653. 

3 Diseases of the Skin, p. 382. 



M. 



CARBUNCULUS. 261 

Before rupture of the furuncle it may be protected by means of an 
ointment or paste containing ichthyol, 1 to 2 drachms (4.-8.) to the 
ounce (30.), or by protecting the surrounding skin with such an oint- 
ment or paste hot antiseptic applications may be applied to the lesion 
itself. A convenient and effective dressing at this stage is found in 
one of the artificial sterilized clays, of which there are a number on the 
market, containing from 30 to 40 per cent, of glycerin and a mild 
antiseptic. Such a dressing may be continued even after the opening 
of the furuncle if care is taken to permit free discharge of the pus. 

The furuncle should be opened freely with a clean incision when 
pus has formed, but not before. Violent squeezing of the furuncle to 
separate its slough or evacuate the contents should never be practised, 
though it is permissible in some instances to scrape out the contents 
with a curette. The cavity should be cleansed thoroughly at least 
twice a day with hydrogen peroxide or with solution of carbolic acid 
or mercuric chloride, and packed with iodoform, boric acid, aristol, or 
other powder. In place of these powders, carbolic acid in crystal or 
in strong solution may be employed. 

Prognosis. — Eventually the worst cases are relieved when unac- 
companied by systemic or visceral disorders, and when the circum- 
stances of the sufferer permit him to pursue the most advantageous 
course (travel, diet, abstraction from business, etc.). The resulting 
cicatrices depend upon the severity of the process. Often they are 
small and in the course of years become scarcely distinguishable ; in 
exceptional cases they are large, persistent, and disfiguring. Lympius * 
calls attention to the serious and even fatal complications (purulent 
arthritis, meningitis, thrombosis of frontal veins, septic infarct in lung) 
which may complicate furunculosis of the face, owing to the vascu- 
larity of the region. 

CARBUNCULUS. 

(Lat. carbo, a live coal.) 

(Anthrax Simplex, Carbuncle. Ger., Karbunkel, Brand- 
schwar; Fr., Anthrax.) 

A carbuncle is an acute, flattish, circumscribed cutaneous and sub- 
cutaneous abscess, usually larger than a furuncle, that is due to the 
presence of staphylococci, and is characterized by dense induration and 
sloughing, terminating in favorable cases by the production of a per- 
sistent cicatrix. 

Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the 
site of the lesion. In cases in which the carbuncle is formidable and 
seated upon or near the head alarming symptoms of prostration, stupor, 
somnolence, and even coma, may be noted. With and without these 
concomitants a dense, dull-red, indurated, and painful phlegmon soon 
appears, varying in size from that of a small hen's-egg to that of an 
orange and even much larger, involving not only the skin, but also 
x Deut. med. Wchnschrft., 1899, xxv., p. 474. 



262 INFLAMMATIONS. 

the tissues beneath. Suppuration finally occurs, but the pus is not 
confined to a single space ; it undermines the' integument and often 
through several apertures leaks out indolently to the free surface. The 
fenestrated or cribriform appearance of the skin covering the carbuncle 
constitutes in this stage one of its most striking features. Through 
these apertures may be distinguished the whitish or yellowish pus- 
soaked sloughs or portions of a single slough, which can at times be 
extracted through the orifice. Often the entire mass separates in a 
single slough involving the skin and subcutaneous tissues, leaving a 
crateriform ulcer of formidable size, which in favorable cases proceeds 
to heal by granulation. The resulting cicatrix is at first of a deep 
violaceous tint and later becomes blanched. It is indelible. 

There is commonly one lesion; at times several simultaneously or 
successively develop. The sites of election are the neck, upper chest, 
buttock, and lower extremities. 

The fever which usually accompanies this process may be mild or be 
severe, or, more commonly in dangerous cases, be of a typhoid char- 
acter. It results unquestionably from sepsis due to unliberated pus 
and necrotic tissue, and is naturally most grave in its consequences 
in patients weakened by previous asthenic disorders. Under these 
unfavorable circumstances the carbuncle may spread at the periphery, 
enclosing islands of necrotic tissue and ill-conditioned pus separated 
by bridges of empurpled, infiltrated, and yielding skin. 

The characteristic lesions of this disease most often appear on the 
back of the neck, the back of the trunk, and the lateral aspect of the 
hips and thighs, usually in a single development, though occasionally 
two or even three carbuncles of small or of medium size may coexist. 
The reason for their appearance in the localities named is clear. It is 
here that the skin is most thick and resistant, and, as a consequence, 
purulent foci when formed are covered in by the most voluminous 
layers of the connective tissue of the corium. 

Etiology. — Anthrax simplex is produced by the obscure causes 
to which reference has already been made as probably effective in the 
production of boils. Carbuncles and boils may coexist; or the one 
lesion may follow the other ; and there may occur intermediate forms 
assignable to either class. The disease is encountered more often in 
men than in women, and in later than in earlier life, simply because the 
tissues constituting its sites of preference offer in these individuals and at 
these ages a greater resistance to the exit of pus. The pus-cocci may 
sustain an etiological or purely an accidental relation to the lesion. 
Carbuncle is at times an epiphenomenon in cachexia, diabetes, albu- 
minuria, syphilis, pemphigus, and exfoliative dermatitis. 

Pathology. — The pathological anatomy of carbuncle has been well 
described by Warren, 1 whose observations conclusively show that the 
inflammatory process here is that seen in the simplest pustule. The 
special symptoms of carbuncle are due solely to the formation of the 
phlegmon beneath the dense and extremely thick masses of fibrous 
tissue found in the back " for the protection of that comparatively 
defenceless portion of the body." The cell-elements, multiplying with 
1 The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. 



CABBUNCULUS. 263 

the intensity of the inflammatory process in the subcutaneous adipose 
tissue, pass upward along the fat-columns, crowd between these and 
push along the horizontal clefts branching from either side, infiltrate 
the derma, pass along the edges of the hair-follicles, fill the papillae 
until the latter " balloon " with pus, ooze to the surface through the 
cribriform aperture in the undermined epidermis, and macerate the 
bundles of fibrous tissue relatively intact that constitute the undetached 
mass of sloughing tissue. 

The constitutional symptoms in carbuncle (pysemic, septicemic, or 
sympathetic) are due solely to pus-imprisonment. The pus-formation 
is due to the presence of the staphylococcus pyogenes aureus and its 
toxin. Back of all lies the favorable soil (in the diabetic, the cachectic, 
etc.) for multiplication of the micro-organism. 

Diagnosis. — It follows from what has preceded that carbuncle and 
furuncle differ solelv in the depth of the starting-point of the phlegmon, 
and the density and. resisting power of the overlying tissue. The car- 
buncle is, therefore, flatter, denser, less rapidly developed, larger, less 
tender, and more painful ; opens by many rather than by one or two 
apertures ; and is followed by larger sloughs, ulcers, and cicatrices, and 
occasionally by fatal results. 

Treatment. — Crucial and other deep incisions in the local treatment 
of carbuncle are certainly inferior in results to the course advocated by 
Wood 1 and Taylor, 2 whose method is employed in cases with complete 
success, namely : a saturated solution of pure carbolic acid is injected 
with a hypodermatic syringe through the several apertures in every direc- 
tion into the sloughing tissues. When the orifices are not sufficiently 
numerous the point of the needle is thrust through the thinned integu- 
ment at the summit of the swelling at several points. The pain is 
severe but short-lived; the tissues are blanched, indurated, and de- 
stroyed ; the slough in a few days is readily separated after division of 
its slender fibrous attachments ; and the ulcer rapidly contracts with 
the sequel of a smaller scar. It is necessary to use pure acid in satu- 
rated solution to prevent absorption of the injected fluid and the result- 
ing toxic effects. 

Relief is afforded in many cases by hot borated lotions and fomen- 
tations with the requisite skill in the surgical dressing of the parts, by 
carbolated lotions, extraction of the slough wholly or in portions with 
the forceps, and the subsequent employment of boric acid, iodol, iodo- 
form, or aristol, or the paste recommended in the treatment of furun- 
cles. An excellent method of withdrawing the purulent and sloughing 
contents of the carbuncle is to apply over it at the proper period an 
exhausted receiver, such as a common cupping-glass. 

Erasion of the entire abscess with a curette and subsequent anti- 
septic dressing is an accepted radical measure of relief for employment 
in proper cases. 

The antiseptic treatment of a carbuncle, however, furnishes the best 
results as regards the comfort of the patient and limitation of the 
disease. By this treatment there is absolutely no surgical interference 

1 Toledo Med. and Surg. Jour., December, 1880. 

2 Australian Med. Gaz., December 1, 1881. 



264 INFLAMMATIONS. 

with the lesion beyond the incisions made for the evacuation of pus. 
Violent squeezing and manipulation of the carbuncle are interdicted ; 
it is freely powdered with boric acid, iodol, or iodoform ; and on it is 
laid soft felt cloth thickly spread with any emollient and antiseptic 
salve, such as the ordinary zinc-salve. Boric acid in powder or iodol, 
thickly dusted over the carbuncle and covered with antiseptic wool, 
will also be found a useful dressing. 

Internally calx sulphurata may be administered in full doses ; it 
has, however, a questionable effect in diminishing the pus-formation. 

Other constitutional treatment may be demanded in furunculosis, 
including the liberal employment of tonics, a generous diet, a strict 
observance of the rules of hygiene, and stimulants when indicated. 
Pyrexic, septicemic, pyemic, and adynamic states require the special 
management of such complications, including cold sponging of the 
body-surface in fever, and the use of quinine, the mineral acids, and 
stimulants, with artificially applied heat in the algid condition. The 
urine should always be examined for sugar and albumin. 

Prognosis. — A serious issue need only be anticipated when the com- 
plications described above are grave in character or they occur in 
asthenic constitutions. 

ANTHRAX. 

(Gr. avdpatj, a live coal.) 

(Malignant Pustule, Splenic Fever Carbuncle. Ft., Pustule 

MALIGNE, CHARBON; Ger. y MlLZBRAND, MlLZBRAND KAR- 
BUNKEL.) 

Anthrax maligna is a carbuncular lesion resulting from infection of 
the skin or other organs of the body with a virus containing the 
anthrax-bacillus, furnished by an animal infected with splenic fever. 

This disease in man, fortunately rare of occurrence, results from 
external inoculation, and is always (See) derived from some animal 
affected with the specific malady variously termed " anthrax," " charbon," 
" splenic fever," " splenic apoplexy," or " Texas fever." After inocu- 
lation with the disease from an infected animal the human subject may 
(a) perish from systemic poisoning wholly septicemic in character with 
few external symptoms ; or, (6) when life is sufficiently prolonged, may 
suffer from visceral symptoms, and develop subcutaneous tumors ; or 
(c) may exhibit the symptoms of the disease now under consideration. 

In from twelve hours to three days after inoculation a painless some- 
what pruritic macule, resembling a flea-bite, first is manifested, usually 
upon the dorsum or other part of the hands or the face to which the 
virus has had access. The macule is followed in from twelve to fifteen 
hours by an inflammatory and pruritic papule, which is transformed 
rapidly into a flaccid vesicle filled with a bloody serum and surmount- 
ing a firm indurated " nucleus " ; or a larger blood-filled bleb develops 
reposing upon a somewhat painful, engorged, and often densely in- 
durated base involving extensively the subcutaneous tissue. One or 
more similar lesions may follow in the surrounding integument, coales- 






ANTHRAX. 265 

cence of which lesions produces a large, angry, oedematous, and often 
gangrenous ulcer with a reddish areola. The area of the skin involved 
may be of the size of that of a small coin or be as large as the palm 
of the hand. The lymphatic vessels and ganglia enlarge, become 
inflamed, and often suppurate ; metastatic abscesss form ; and the consti- 
tutional symptoms supervening are those described in connection with 
Equinia. If recovery is to ensue, the gangrenous mass will slough as 
in favorable cases of carbuncle ; if the result is to be fatal, the process 
rapidly is aggravated by oedematous infiltration extending to a wider 
area and by greater tissue-necrosis. 

In some cases the accompanying fever is high, with marked delirium ; 
in other cases it is of a typhoid character. Death results from shock, 
septicemia, or exhaustion, though in cases in which the lesion is circum- 
scribed and unattended by constitutional symptoms recovery may 
ensue. 

Etiology. — This disease is induced by infection from one of the 
lower animals, usually horned cattle, that suffer from charbon or 
splenic fever, and are handled by herders, ranchmen, etc. The sus- 
ceptibility of the carnivora to the disease is very much less than that 
of the herbivora. It is claimed that not only direct inoculation may 
produce the disease, but that it may be transmitted through the medium 
of flies and other insects. More recently it is 
asserted that food, drink, and even inspired air Fig. 44. 

may be the medium by which the disease is con- I 

veyed. The victims are chiefly male adults. m # 

Pathology. — Since the first investigations re- ^ "»■■■! «ao 

ported in 1864 by Davaine to the French Acad- '' /%\^A 
cmy, Pasteur, Klebs, Koch, Carnevin, and others f ~j) . • 

have demonstrated that splenic fever is solely JM& ^ 'IT 
due to the multiplication in the blood and tissues \^## ^3^ 
of a rod-shaped bacillus, the bacillus anthrads, #""" 

which is non-motile and transparent, measuring Malignant pustule bacilli 
from 1 to 1.5 ;i to 5 to 20 //. Under culture the ^pus-corpuscles. (About 
bacilli may develop long filaments many times 

larger than the original rods, with a distinct sheath about a protoplasmic 
cylinder, which filaments after segmentation furnish oval shining spores. 
These spores have been cultivated in generations, with resulting germs 
that produced the disease artificially in the lower animals. 

The pathological anatomy of malignant pustule is that of carbuncle, 
with the added fact that specific bacilli and spores are everywhere 
present in the blood and debris of tissue. There is an almost char- 
acteristic oedema of the papillary body, according to Unna : the mar- 
gin of the epithelium is well preserved ; there is an acute vesicular 
elevation of the horny stratum without a previous breaking up of the 
connective-tissue layer, and this induces a stretching of all the cavities 
in a vertical direction. 

Diagnosis. — The characteristic features of typical malignant pus- 
tule are its central eschar, its crown of vesicles, and its indurated 
base. In establishing a diagnosis care must be taken to avoid one 
source of error. Malignant pustule in man is not of frequent occur- 



266 INFLAMMATIONS. 

rence in America, but occasionally various cutaneous eruptions are pro- 
duced upon the hands after contact with animals or their hides upon 
which chemical solutions have been applied for the destruction of lice. 
These solutions usually contain arsenic, corrosive sublimate, or other 
substance capable of exciting a localized dermatitis. Chancre of the 
face, carbuncle, and poisoned wounds are all differentiated by their 
relatively indolent course and the absence of gangrene. 

The Treatment is to be conducted on the principles of general 
therapeutics. Deep incisions of the lesion, extended to the subcutaneous 
connective tissue, are often successful when practised before the occur- 
rence of general symptoms. 

Successful results have also been obtained from excision and iodo- 
form dressings. Hebra was not in favor of early cauterization of the 
malignant pustule, and it may be considered a questionable method of 
procedure. A grave case of malignant anthrax is recorded in which 
recovery ensued after hypodermatic injection of tincture of iodine. 
Three syringefuls of pure tincture were deposited beneath the skin at 
the periphery of the diseased surface, and lint saturated with the same 
fluid was applied over the slough. Internally, 1 5 drops of iodine tincture 
(1.), with 3 grains (0.20) of potassium iodide, were also administered. 
Normal cicatrization followed in this and six other cases recorded. 

Crucial incisions with the free application afterward of pure car- 
bolic acid have been followed by good results. Internally, sodium 
hyposulphite and quinine are successfully employed. The febrile, 
typhoid, and adynamic features of the disease are to be treated in 
accordance with the recognized principles of general medicine. 

Prognosis. — The disease proves fatal in about one-third of all cases. 
Early excision gives promise of satisfactory results. 

EQUINIA. 

( Lat. equuSf a horse. ) 

(Glanders, Farcy, Malleus. Fr., Morve, Farcin ; Ger., 

KOTZKRANKHEIT, MALIASMUS.) 

Equinia is a contagious, virulent, and inoculable disease, transmitted 
to man from the horse, mule, ass, or other animal ; and produced by a 
bacillus resembling that of tuberculosis. It is conveyed either directly 
or mediately by the application of cloths and other articles which have 
been in contact with the bodies of infected animals. 

Symptoms. — The acute form of this disease commonly follows a 
period of malaise lasting a few hours or a few weeks, during which period 
the patient complains of vague pains of a rheumatoid type, followed 
by thermal variations. The body-temperature rises rapidly to the point 
of danger, with chills, fever, diarrhoea (often following constipation), 
and rapid exhaustion, the picture being suggestive of acute septicaemia. 

The cutaneous symptoms begin often with an erysipelatoid blush, 
the infected and swollen surface, also producing papules, vesicles, 
pustules, and bullae, with dense but ill-defined induration of the sub- 
cutaneous tissue ; or reddish and yellowish papules appear, which, as 



EQUINIA. 267 

in the case of the fluid-containing lesions, coalesce and furnish a bloody 
discharge. These symptoms, in the case of inoculated disease, may 
develop on the site of the healed or healing wound of entry of the 
virus, and later become generalized. Sloughing ensues more or less 
rapidly, sometimes with extensive gangrene, though the patient often 
succumbs before the culmination of the morbid process. The lymph- 
atic vessels are swollen and well denned, often indurated nodules (farcy- 
buds) forming in the lymph-glands and -channels. These symptoms 
chiefly affect the face, hands, feet, and other exposed parts of the 
body. There is often a sanious or purulent and offensive discharge 
from the nostrils, the mouth, and the eyes, the inflammatory process 
spreading rapidly to the deeper mucous surfaces. This catarrh, chiefly 
nasal in site and declared conspicuously by the nasal voice due to the 
blocking up of the nostrils by the viscid, foul-smelling, hemorrhagic dis- 
charge, is one of the most characteristic features of the malady, and is 
of importance in the diagnosis. 

In the chronic ^orm of the disease the nasal catarrh is less conspic- 
uous at the outset, though later it may be a prominent feature of the 
malady. A few days or weeks after infection, pustules, as in the acute 
form, resembling those of variola, but flattened and never umbilicated, 
begin as vesicles or even as papules, coalesce to bullae, occur in succes- 
sive crops, and proceed to the production of multiple abscesses, poorly 
denned on the extremities and about the face, much more rarely de- 
veloped on the trunk. These abscesses may be of phlegmonous type ; 
or be deep, brawny infiltrations with purulent foci, extending over 
months of invasion and decline of the disease. From these abscesses, 
pea- to nut-sized over the face, larger on the limbs, flows an abundant, 
sanious, semiliquid or viscid, yellowish, offensive pus. Ulcers form at 
many points, with purplish borders, oval or roundish countour, and thin 
edges, suggesting the scrofulous ulcer of classical type. The edges may 
be soft or indurated. By this multiplication or coalescence the lips, 
nose, eyelids, and other parts of the face may in part or wholly be 
destroyed. The disease may steadily advance or may seem to be 
arrested for a time and reawaken to activity. Meantime the lymphatic 
glands are either unchanged or are enlarged by sympathy. In the 
course of months or years there is a fatal issue. The disease is, for- 
tunately, rare. 

Etiology and Pathology. — Equinia is almost invariably produced 
by infection from horses, a history of contact with such animals being 
one of the important points in establishing a diagnosis, though rarely 
it is transmitted also from man to man. The infection is produced 
by the glanders-bacillus (Weichselbaum, Schiitz, Loffler, Bouchard). 
This organism is nearly of the size of the tubercle-bacillus, having 
been cultivated and found capable of producing the disease in the lower 
animals after injection of cultures. The bacilli are abundant in papules, 
abscesses, blood, and brain-tissue. 2 

1 For diagnosis by Strauss' method — injecting glanders bacilli into the abdominal 
cavity of male guinea-pigs, with production of peculiar suppurative lesions of the scrotal 
peritoneum— see Frothingham, Jour. Med. F*esch., 1901, vi., p. 331. 

2 Cf. Coleman and Ewing, Jour. Med. Kesch., 1903, ix., p. 223 (report of case with 
autopsy, histological and bacteriological findings, and bibliography). 



268 INFLAMMATIONS. 

The Treatment is that of the septic condition, and is of little avail. 
The Prognosis is in the highest degree grave. 

DISSECTION-WOUNDS AND ANIMAL POISONS. 

Aside from verruca necrogenica, or anatomical tubercle, described 
in the chapter on Tuberculosis Cutis, lesions generally known as 
"dissection-wounds" occur with symptoms of acute poisoning upon 
the hands of those exposed in post-mortem examinations and dis- 
sections. At the inoculation-point, which may be either the site of 
a former abrasion, a rent, or the mouth of an open follicle, a painful 
vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla 
rapidly rises from an angry and indurated base with hypersemic areola 
of dull-red shade. Suppuration, crusting, or ulceration, limited to 
the seat of the lesion, may follow ; or there may occur lymphangitis 
in various grades with consequent pysemic or septicemic involvement 
of the system. Suppurative and non-suppurative axillary buboes are 
common. Gangrene and necrosis of the soft parts and the bones, espe- 
cially the phalanges, may ensue, as may also a fatal result from the sys- 
temic disorders named. Rarely an acute and fatal septicaemia may 
result when the lesion at the point of inoculation is so slight as to pass 
unnoticed. In a few cases chronic marasmus is induced. 

Post-mortem pustule originates from infection with cadaveric poisons 
in the dissecting-room or dead-house. A pruritic macule either at the 
site of an abrasion or elsewhere soon develops, and is transformed into 
a vesico-pustule with a reddish halo which bursts, and is covered with a 
crust beneath which pus repeatedly forms. Occasionally there is coin- 
cident adenopathy. 

The nature of the infection varies in different cases. It is most 
commonly due to pyogenic bacteria, but may be caused by the specific 
micro-organisms of tetanus, erysipelas, anthrax, or other infectious 
disease. The absorption of toxins resulting from the decomposition 
of animal tissues is undoubtedly an important factor in the infection. 

The treatment is to be conducted in accordance with the principles 
already described. Prophylaxis, by proper protection of the hands, 
and the immediate cleansing and disinfection of any accidentally 
wounded point, are of the highest importance. Wet boric acid dress- 
ings, the application of sublimate or iodoform gauze, and painting with 
aqueous solutions of pyoktanin blue are usually efficient. 

Pustules and other Lesions resulting from Wounds 
inflicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites or the stings of flies, 
fleas, mosquitoes, ants, bees, hornets, etc. At other times, however, 
serious and even fatal consequences have been recorded. The wounds 
produced by the tarantula and the scorpion (which frequently lurk in 
the clusters of tropical fruit now imported to almost every part of the 
United States), as also of venomous reptiles, may prove to be grave. 
Urticarial, vesicular, pustular, papular, bullous, and petechial lesions 
may thus originate and be the cause of a more or less severe dermatitis 



ORIENTAL SORE. 269 

with toxic symptoms. In the latter event it is common to administer 
as remedial agents alcoholic stimulants as freely as they can be ingested 
with hot borated fomentations at the site of the lesion. 



ORIENTAL SORE. 1 

(Mycosis Cutis Chronica, Lupus Endemicus, Aleppo Evil, 
Biskra Bouton, Delhi Boil, Oriental Button, Oriental 
Ulcer, Gafsa Button, Afghan Plague, Taschkat Ulcer, 
Natal Sore. Fi\, Bouton d'Orient, Chancre du Sahara, 
Clou de Biskra; Ger., Endemische Beulenkrankheit.) 

The morbid condition known as oriental sore is one designated not 
merely by the synonyms detailed above, but by a series of names in 
the Arabic, Turkish, Persian, and Russian languages which in most 
instances refer to the same disease. It is an endemic cutaneous affec- 
tion, recognized chiefly in tropical and subtropical countries, more 
particularly in those which have given titles to the disease, such as 
Biskra, Gafsa, Aleppo, Bagdad, Delhi, etc. It occurs in Morocco, 
Algiers, Tunis, Egypt, Crete, Cyprus, the Crimea, Syria, Mesopotamia, 
Arabia, Persia, Turkestan, India, Brazil and probably other portions 
of South America. 

Symptoms. — The disease begins as a circumscribed maculo-papule 
having a firm, shot-like feel starting from an hypersemic and infiltrated 
portion of the skin. In the course of a few days furfuraceous scales 
cover the surface of a well-defined papule, which being agglutinated 
by the secretion from beneath of a thin fluid form a yellowish-brown 
thick adherent crust. On the removal of this crust there is exposed 
beneath, a shallow ulcer which extends peripherally and exudes a secre- 
tion which tends to reproduce the crust beneath which the ulcer spreads. 
Satellites in the form of new papules and ulcers form in the vicinity 
which often merge and produce a single sharp-bordered, rounded or 
oval, punched-out ulcer with granulating floor, oadematous base, out- 
lying areola, and bulky crust. The dimensions of the sore vary from 
8 to 12 or more centimetres in diameter. Repair after a period of 
from tAvo to twelve or more months ensues by the usual processes of 
granulation and cicatrization. The resulting cicatrix is usually sunken, 
at first pigmented, and exceedingly deforming when, as is often the 
case, it is displayed upon the face. 

The parts chiefly affected are the face, especially in young subjects, 
the . hands, feet, arms, and legs ; commonly the palms and soles, the 
scalp, and trunk are spared. In some cases the primary lesion does 

1 Scheube, Falcke, Cantlie, Diseases of Warm Countries, Phila., 1903, p. 534 ; Manson 
Tropical Diseases, 1900, p. 476; Brault, Annales, 1899, 3 s., x., p. 85 and p. 226 
Brocq et Yeillon, Ibid., 1897, 3 s., viii., p. 553; Doulas, Jour. Mai. cutan., 1903 
6 s., xv., p. 190; Kuhn, Johanne, Virchow's Archiv, 1897, p. 372; Lemarsky, Eev 
internal, de Med. et de Chir., 1897, viii., p. 78; Lowenhardt, Eep. Trans. Germ. Assoc 
of Surg., xxviii., Congr. 1899, p. 37 ; Morvan, Jour. Cutan. Dis., 1900, xviii., p. 230 
Moty, Annales, 1893, 3 s., iv., p. 41, and 1897, 3 s., viii., p. 726 ; Eiehe, Vierteljahr. 
1886. xiii., p. 805; Unna, Histopathology, 1894, p. 472; Wright, Jour. Cutan. Dis. 
1904, xxii., p. 1. 



270 INFLAMMATIONS. 

not proceed to ulceration ; in yet other cases, instead of one there may 
be a dozen or even forty separate sores ; the lesion, like all others, may 
be complicated by the epiphenomena of erysipelas, phagedena, lymph- 
angitis, abscess, phlebitis, etc. Relapses occur. 

Etiology. — Oriental sore is contagious, autoinoculable, and trans- 
missible to and from the lower animals by direct contact or by the 
medium of insects, articles of clothing, etc. It affects indiscrimi- 
nately persons of both sexes, of all ages and nationalities, those vary- 
ing as to vigor and occupation. It often attacks children after the 
completion of the second year, and seems at times to confer a species 
of immunity against second attacks, though many instances tend to 
disprove the possibility of such protection. Those exposed may 
develop symptoms in the course of a fortnight ; though in other cases 
it would seem that months may intervene before infection is estab- 
lished ; briefly there is no fixed period of incubation. 

Pathology. — The parasites taking a violet stain and recognized by 
Cunningham and Firth are believed by Riehl to be results of hyaline 
degeneration of protoplasm ; all inoculations with pure cultures of 
micrococci supposed to be the effective agents of the disease have been 
negative in results. The parasitism of the disease cannot be ques- 
tioned, for Wright, in the case of a female child nine years of age, 
born in Armenia, examined a tropical ulcer which was excised, and 
recognized in smear preparations round, well-defined bodies 2 to 4 fx 
in diameter, each containing a lilac-colored mass near the periphery of 
the body, which were present in large numbers and supposed to be 
protozoa. They were recognized as intercellular in situation, and 
multiplied by fission without spore-f jrmation. Wright gave the name 
helcosoma tropicum to these bodies, and believes them to differ from 
the organism recognized by Firth by reason of the characters described 
above. 

Sections made of primary papules reveal round-cell infiltration of 
the derma, the presence of multinuclear and giant-cells, and of leuco- 
cytes, the deposit being most plentiful about the vessels of the skin and 
the coil-glands. In the midst of the infiltration Unna has seen necrotic 
granules ; the surviving hairs are altered in shape and sheath ; 
rounded or oval cavities surround the hair-pouches ; the blood-vessels 
may be obliterated by endothelial plugs. 

The Diagnosis, in localities where the affection is endemic, is 
attended with but little difficulty ; but among the classes in which 
the disease is especially likely to be encountered, it is confounded 
most often with syphilis. The strictly local character of the oriental 
sore and the duration of that disease furnish ample facility for its dis- 
tinction from other ulcers of a specific origin. 

Treatment is by cauterization, excision, erasion, asepsis, and the 
methods employed by the resources of modern surgery in the manage- 
ment of similar affections. By many local authorities the milder and 
soothing rather than the more severe (destructive) measures of treat- 
ment are advocated. 

The Prognosis is in general favorable, save in the matter of 
deformity left by the resulting scars. A fatal result has rarely been 



ULCERATING GRANULOMA. 271 

recorded, as the result of some one of the possible complications of 
the disease. 

Bucharest Boil. — Finkelstein l describes under this title a pain- 
ful furuncular affection differing from the oriental sore, preceded by 
pain and beginning with an elevated nodule which in the course of 
two or three weeks, during which period there are accesses of fever, 
bursts and after discharging leaves a contracted cicatrix which may 
also be complicated with articular anchylosis. The abscess may be as 
large as a child's head, and commonly is situated either in the inguinal 
or lumbar region. The subjects of the disease are usually between 
eighteen and thirty-five years of age, suffer but little in the general 
health, and rarely perish of the affection, which is believed to originate 
in unsanitary conditions of living. FrankePs pneumococci, the com- 
mon streptococci, and staphylococci have been found in the pus. No 
malarial parasites have been recognized. 

ULCERATING GRANULOMA OF THE PUDENDA. 2 

(Serpiginous Ulceration of the Genitals, Groin Ulcera- 
tion, SCLEROTIZING GRANULOMA OF THE PUDENDA, PERFO- 
RATING Granuloma of the Thigh, Granuloma Inguinale 
Tropicum. Ger., Das Venerische Granulom.) 

In 1896 Conyers and Daniels first recorded observation of this 
disease in negroes resident in British Guiana and among East Indians. 
The malady has since been observed among the natives of the Fiji 
and Solomon Islands and the New Hebrides. Contributions to the 
subject have been made by Maitland, MacLeod, Manson, and others. 

Symptoms. — The disease occurs in both sexes after the puberal 
epoch, chiefly in women, and is seen most often in the genital region 
and the parts provided with long hairs, but it has been observed on 
the cheek, the lips, and inside the mouth. The lesions are vivid-hued, 
shining, verrucous, vegetating nodules of granulation-tissue. These are 
at first circumscribed thickenings and elevations. The thin overlying 
epidermis is excoriated readily, and exposes a hemorrhagic surface 
which may ulcerate. The granuloma spreads both by autoinfection 
and peripheral extension, producing eventually, possibly after years 
of slow extension, a dense contracting, irregularly nodulated scar- 
tissue, here and there sprinkled with islets of actively progressing 
disease. Unevenly pigmented areas are made up of excoriated or 
partly cicatrized and corded tissue, often with a narrow serpiginous, 
elevated, glazed, pinkish or reddish border. The process is superficial 
and as a rule unaccompanied by coincident adenopathy. 

The parts most often invaded are the labia and vagina of women ; 

1 Deutsch. med. Wchnschrft., 1899, cited by Scheube. 

2 Bibliography : Conyers and Daniels, Brit. Guiana Med. Ann., 1896, viii., p. 13 ; 
Crocker, Diseases of the Skin, p. 1076 ; Daniels, Brit. Guiana Med. Ann., 1898, x., p. 
49; Fowler, Ibid., 1899, xi., p. 22; Galloway, Brit. Jour. Derm., 1897, ix., p. 133; 
MacLeod, K., Jour, of Trop. Med., 1899, p. 175; Maitland, J., Lancet, 1899, ii., p. 
1624 : Manson, loc. cit., p. 471 ; Powell, A., Ind. Med. Gaz., 1899, p. 187 ; Scheube, 
Falcke, Cantlie, loc. cit., p. 54. 



272 INFLAMMATIONS. 

in men the penis, urethra, and scrotum ; in both sexes the ano-rectal 
region, pubes, groins, and rarely the bladder. Subjective sensations 
are not conspicuous ; anaemia and cachexia occasionally result. Offen- 
sive discharges are produced in advanced cases. The disease is aggra- 
vated in regions of pressure, friction, and moisture. Manson describes 
the affected surface as " an area of white or irregularly pigmented, 
perhaps excoriated, contracting, folded, and dense cicatrix, surrounded 
by a narrow, serpiginous, irregular border of nodulated, somewhat 
raised, red, glazed, delicately skinned or pinkish, superficially ulcerated 
or cracked new-growth." 

Diagnosis. — The disease is to be differentiated from syphilis by the 
absence of adenopathy, by the extreme chronicity of the process (at 
times extending over ten years with but few changes), and by the special 
features outlined above. It is not amenable to antisyphilitic treatment. 

Etiology. — The disease attacks persons of all races, but chiefly 
negroes ; and individuals of both sexes, but mostly women. The sub- 
jects are as a rule young adults, though the disease is seen in aged 
persons. The affection is contagious, autoinoculable, and frequently 
venereal in origin though not syphilitic. The precise character of its 
virus is unknown. 

Pathology. — According to Galloway, the lesions are tumors of 
infectious granulation-tissue, which begin with a small-cell (plasma- 
cell) infiltration of the papillary layer of the corium and of elongated 
rete-pegs which crowd before them as they advance the fibres of the 
corium. The overlying epidermis is thinned or absent ; the vessels 
dilated ; the glandular tissue not greatly altered. No caseation occurs, 
and no giant-cells are seen. 

The Treatment is by excision, which Manson prefers on account 
of the marked tendency to recurrence in many cases. Curettage and 
subsequent cauterization have been successful. Mercury and iodine 
salts are of little if any value. 

PHAGEDENA TROPICA. 

(Tropical Sloughing Phagedena, Ulcer of Yemen, Aden- 
Ulcer, Cochin China Ulcer, Mozambique Ulcer. Fr., 
Ulcere phagedenique des Pays Chauds, Ulcere endem- 
ique, Phagedenisme des Pays Chauds, Sarmes or Sarnes ; 
Ger. y Tropische Phagedanismus.) 

Phagedenic ulceration, varying in type and severity, has been 
observed in almost all of the tropical countries of Europe, Asia, 
Africa, and America. While it is not certain that the several disor- 
ders to which the name has been given in different parts of the world 
designate the same morbid state, it is clear that many conditions to 
which the same has been applied are identical in their nature. 1 

1 Scheube, Falcke, Cantlie, loc. cit., p. 544 ; Manson, loc. cit, p. 606 ; Blaise, Gaz. 
hebd. de Med. et de Chir., Oct. 10, 1897; Brault, J., Annales, 1897, 3 s., viii., p. 165; 
Boinet, Ibid., 1890, 3 s., i., pp. 210 and 307; Crendiropoulo, Ann. de l'Inst. Past., 1897, 
xi., p. 784; Dantec, Le, Arch, de Med. Nav., 1885, p. 448, and 1899, lxxi., p. 133; 
Dempwolf, O., Arch. f. SchifEs n. Trop. Hyg., 1898, ii., p. 282 ; Legrain et Fradet, 
Annales, 1897, 3 s., viii., p. 781 ; Kasch, Ch., Allg. med. Ctr.^Ztg., 1896, lxv., p. 951. 



PHAGEDENA TROPICA. 273 

Symptoms. — The onset of the disease is commonly at some point 
of the body-surface which has been the site of a traumatism slight or 
severe in grade (excoriations, contusions, insect-bites ; or the point 
where there has been a localized dermatitis from any cause — e. g., 
syphilis, pus-infection, eczema, etc.). There may be a predisposition to 
the affection in consequence of a previous state of depressed health. 
The disease may begin with a single or with multiple lesions, which 
usually develop over the dorsum of the foot or over the anterior face 
of the leg. 

The first lesions are vesicular or bullous in character, the bursting 
of which releases a serous or seropurulent fluid. Ulceration promptly 
follows with the formation of a necrotic floor made up of indolent 
granulations, and grayish, pseudomembranous or pultaceous, partly 
adherent sloughs. The edges are undermined, the odor exhaled from 
the sore putrescent, and the extension of the disease from centre to 
both surrounding skin and subcutaneous tissue exceedingly rapid. In 
the progress of the sore, muscles, tendons, aponeuroses, periosteum, and, 
in cases, even bone, joints, and the larger bloodvessels may be attacked. 

The affected part is exquisitely painful and tender ; the surround- 
ing tissues often oedematous and actively congested ; the general con- 
dition of the sufferer one of extreme adynamia, which may be 
accompanied by chills, fever, and the signs of a dangerous septicaemia. 
A fatal result may occur from any of the common complications of 
such a state (intercurrent diarrhoea, pneumonia, hemorrhage, etc.). 

When repair ensues, the improvement in the local condition of the 
sore is by the usual course of granulation, casting off of sloughs, and 
cicatrization. Mutilations, deformities, anchyloses, contractures, and 
relapses with fever are not rare. 

Etiology. — The disease is unquestionably more prevalent in those 
residents of the tropics who have been debilitated by malaria, excessive 
heat of the climate, malnutrition from whatever cause, and similar 
agencies. Natives as a rule suffer more than visitors from temperate 
zones. Beggars, men chiefly engaged in severe toil, those exposed in 
hot and rainy seasons, the uncleanly, and those wretchedly housed, 
furnish the larger number of all patients. 

Pathology. — No specific organism has yet been demonstrated to be 
efficient in the production of the disease. Le Dantec recognized 
bacilli, 7 to 12 ju, in length, and immobile. Those seen by Blaise 
were longer and bent ; those by Crendiropoulo were capable of destroy- 
ing rabbits and pigeons, the cultures giving off a putrid odor. The 
rods were two or three times as long as they were broad, with rounded 
extremities. Sufficiently reduced they produced phagedenic sores in 
the lower animals. 

The Treatment of tropical sloughing phagedsena is, first, by support 
of the general health in accordance with the methods universally accepted 
in science ; by thorough erasion, cauterization, and aseptic dressings. 

Stoker has employed oxygen and air locally. Where it is practi- 
cable, the best local treatment is continuous immersion of the part in 
water of a temperature as high as is grateful, medicated with boric acid. 

As the disease is infective, patients should be isolated 

18 



274 INFLAMMATIONS. 

PHLEGMONE DIFFUSA. 

(Gr. (fkeyfiovrj, an inflamed tumor.) 

The word phlegmon is employed by most English and American 
writers to indicate a circumscribed cutaneous inflammation which ter- 
minates naturally in suppuration, and which, as to the tissues involved, 
is larger than an ecthymatous pustule, yet is not large enough to be 
termed an abscess. Circumscribed phlegmons are represented by 
most furuncles, and, at one stage of their career, also by carbuncles. 
In the disorder under consideration, however, the symptoms, both local 
and general, are far more serious than either furuncle or carbuncle. 
The disease is particularly prone to develop in children, especially 
infants, and in women. The first evidence of trouble may be a severe 
chill followed by high fever and a deep-seated hammering pain, felt in 
the part which is the seat of the disease. This site is soon recognized 
as an cedematous area, of dull-red or livid hue, tensely infiltrated, of the 
familiar brawny type and indeterminate outline. All these symptoms, 
which rapidly increase, as resolution is rarely attained, are followed by 
suppuration at one or more points. In diffuse phlegmon, however, 
the brawny tenseness of the inflamed skin has been so great that, as a 
consequence, vascular thrombosis occurs and the circulation is greatly 
impeded between the points at which pus forms or about a single point. 
The tissues then become more or less necrotic, both during and after 
the formation and evacuation of pus. 

The fever meantime may abate or may entirely remit, or, in grave 
cases, may steadily persist. In the latter event the subcutaneous tis- 
sue, fasciae, periosteum, bones, joints, and ligaments may be involved. 
But in favorable cases the systemic condition is greatly improved 
when pus is no longer deeply or extensively formed, and when the 
gangrenous shreds and sloughs are well loosened or are entirely 
removed. 

The " acute purulent oedema " of English authors and the gangrene 
faudroyante of the French may be regarded as severe types of diffuse 
phlegmon. In most of these grave cases patients die septicemic be- 
fore complete evolution of the cutaneous inflammation is reached. In 
other cases the affected part, suddenly losing its tense, brawny hard- 
ness, becomes emphysematous or crepitates with bubbles of gas pro- 
duced by decomposition. The patient may then become somnolent 
or delirious, or be the victim of an intercurrent and fatal involvement 
of the kidneys, lungs, liver, spleen, or bowels. 

The Treatment of diffuse phlegmon is largely surgical. Incision, 
drainage, and disinfection are the three essential requirements. These 
measures thoroughly assured, the systemic treatment is by quinine, 
stimulants when indicated, and the accepted remedies for the typhoid 
condition generally, including rest in the recumbent posture and a 
proper supply of wholesome air and food. Amputation of limbs may 
be necessary to save life. 

The Prognosis rests almost entirely upon the extent, diffusion, and 
severity of the local inflammation, and upon the systemic condition of 
the patient. In a previously healthy subject, with good hygienic en- 



COCCOGENOUS SYCOSIS. 275 

vironment and the absence of thrombosis, pyaemia, septicaemia, and ery- 
sipelas, the result will generally be favorable. With the reverse of 
these conditions the outcome may be serious as regards the loss of a 
limb, deformity, or a fatal issue. 

SYCOSIS. 

(Gr. cvkov, a fig.) 

The title " sycosis " no longer indicates an idiopathic affection. It 
is employed in these pages to designate a group of different disorders, 
which, affecting for the most part the region of the male beard, may 
be for practical purposes classified as follows : 

Coccogenous Sycosis includes the most numerous of the cases to 
which the term "sycosis non-parasitica " was once given, and which are 
all due to invasion of the pilo-sebaceous crypts by pus-cocci. These 
pyogerjic organisms may be either primarily or secondarily effective in 
producing the symptoms of the disease. In many cases a suppu- 
rative folliculitis follows the disorders included in the group last 
named. 

Bacillogenous Sycosis is described by Tommasoli. 1 

Hyphogenous Sycosis (Barbers' Itch, Ringworm of the 
Beard) is due to the presence of either the microsporon Audouini or 
the trichophytons (Trichophytosis Barbje). It is described in this 
work among the Tineae. 

A group of Scar-leaving Sycosiform Dermatoses (Lupoid Sy- 
cosis, Ulerythema Sycosiforme, etc.) may also be recognized which 
differ somewhat from those named above. They include the pseudo- 
sy coses, the eczemas limited to the region of the beard with acneiform 
features, the eczemas of the same region with seborrhceic complications, 
certain forms of lupus erythematosus of the beard, and the still rarer 
sycoses possibly due to tuberculous infection of pustular lesions of the 
bearded face. 

COCCOGENOUS SYCOSIS. 

("Non-parasitic" Sycosis, Sycosis Vulgaris, Sycosis Staphy- 
logenes, Mentagra, Ficosis, Folliculitis Babb^. Ger., 
Bartfinne, Bartflechte ; 'Ir. 9 Sycose.) 

Symptoms. — The lesions appear upon the face, involving one or 
both cheeks successively or simultaneously, the chin, the upper lip, the 
eyebrows, the scalp, the axillae, and the pubes. The disease, however, 
is almost always limited to the region of the beard in men. In this 
respect sycosis differs from acne and other disorders of the sebaceous 
glands of the face with which authors have sought to identify it, since 
not only is it, as a rule, strictly limited to the region of the beard, but 
also the non-hairy portions of the face of the patient are free from 
comedones, acne-lesions, and other symptoms of a cutaneous disorder. 

When seated upon the upper lip the first symptoms may be those of 
1 Monatsch. f. prakt. Derm., 1883, vii., p. 403. 



276 INFLAMMATIONS. 

a nasal catarrh ; seated elsewhere an eczematous attack may precede 
the onset of the disease. It may be ushered in with the acute symptoms 
exhibited in the early stage of some forms of eczema, and with tume- 
faction accompanied by a sensation of heat and burning ; but often a 
few isolated and indolent lesions, the presence of which scarcely 
awakens attention, are the first traces of the disorder. Soon there may 
be recognized a larger or smaller number of discrete, pin-point to split- 
pea-sized, flattened or conical, reddish and painful papules, tubercles, 
or pustules, the anatomical seat of which is distinguished as the pilary 
follicle because of the penetration of each lesion by a filament of hair. 
These lesions may persist, and when typically discrete and visible at 
the part at which the hair makes its exit from the duct of the follicle 
they suggest the appearance of the surface of the fig, whence the disease 
derives its name. They are apt to occasion a burning and at times a 
decidedly pruritic sensation when, being picked or torn open by the 
fingers, the pus concretes into a crust at the base of the hair. In 
severer cases these lesions, while not coalescing, are so closely set 
together as to form 'a patch of continuous infiltration. These patches 
may be weeping or be crusted ; in the latter case the crusts are apt to 
be small and numerous, each crust being limited to the shaft of a single 
hair, and leaving when removed a minute crateriform excavation at the 
mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and, 
sooner or later, distinct patches of disease are thus formed. When 
fully developed the surface of the skin is reddened, swollen, infiltrated, 
and thickened ; covered irregularly with papules, pustules, crusts, and 
scales, and frequently with excoriations. The disease often lapses into 
chronic conditions, usually the result of improper treatment, and in 
ancient cases the deformity is characteristic and totally unlike that 
produced by the vegetable parasites. The hairs are usually fixed 
firmly in their follicles, but from those in which active suppuration is 
in progress the hairs may be plucked without occasioning much pain. 
In cases which have been treated for years the hairs are thinned and 
decidedly lack vigor. 

In typical and neglected cases of long standing, in which the region 
of the beard is involved, an important clinical feature is the symmet- 
rical, general, and uniform involvement of the entire surface. The 
picture of one cheek is very nearly that of the other. The sparse 
hairs scarcely serve to disguise the reddened, tumid, painful surface 
beneath, which displays the severe lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli- 
cate the process. Sycosis is occasionally acute in its course, but is 
more often chronic and rebellious. A typically chronic and untreated 
case of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs, described above as a consequence of 
long persistence of the disease, is far more characteristic than any 
distinctly resulting alopecia ; the latter, however, very rarely occurs, 
but is then remediless. The same may be said of resulting cicatriza- 
tion, which is one of the rarest consequences, and which is generally 
due to bacillogenous infection. 



COCCOGEXOUS SYCOSIS. 



277 



The absence of certain symptoms in this disorder is as significant as 
is the presence of others. Adenopathy of the cervical glands is very 
rare, but when present it should awaken suspicion of another malady. 
The disease when of longest persistence as to time produces great 
unsightliness, but not the deep-seated, subcutaneous, small- or large- 
nut-sized nodules or tubercles, forming the " lumps " so characteristic 
of trichophytosis of the beard. Sycosis vulgaris is a disease of chronic 
course, which may endure for years and be characterized by relapses and 
aggravations, but is entirely curable ; it is only in neglected and im- 
properly treated cases that such persistence may be expected. 

Scar-lea vixg Sycosiform Dermatosis (Lupoid Sycosis, Ulery- 
thema Sycosiforme, Seborrhee depilaxte). — Under these titles 
has been described a somewhat rare affection of the skin of the bearded 
face in men, the symptoms of which at the outset are practically those 
of sycosis vulgaris. In the course of the disease, however, whether in 
consequence of an added infection or as the result of the evolution of 
the malady, a change occurs in which the hair-follicles atrophy and 
considerable scarring results. The scars are often irregularly depressed 
between ridges and linear elevations of the surface. By Unna this 
dermatosis is grouped with a class of disorders to which he has given 



IS 


Fig. 45. 


■Htettll 





Lupoid sycosis. 

the title of " ulerythemata." The disease is at times a tuberculous 
complication of ordinary sycosis or one dependent upon the presence 
of tubercle-bacilli, as we have had occasion to demonstrate. The course 
of the affection is exceedingly chronic, lasting, with alternations of 
improvement and aggravation, for several years. According to 



278 INFLAMMATIONS. 

Robinson, the inflammation in these cases spreads peripherally upward 
or downward with a narrow infiltrated margin. The lesions outside of 
the follicles may be papular, vesicular, or pustular in type. The 
tendency to extension from a given centre and to irregular scarring are 
the chief characteristic features of the malady. 

Many of these cases strongly suggest in their features the symptoms 
of lupus erythematosus. In some instances the two affections are 
indistinguishable. The malady is exceedingly obstinate and often 
requires severe local treatment. 

Etiology. — Sycosis vulgaris is unquestionably due to either primary 
or secondary invasion of the pilo-sebaceous follicle by micro-organisms. 
Obviously in many cases there is a special reason for the accessibility 
of the germs to the crypts where they are lodged. Shaving, and the 
use in common of towels, brushes, combs, etc., in public establishments 
(club-houses, barber-shops, hotels), and the employment of pillows, 
lounges, and reclining-chairs in public resorts are often the origin of 
the mischief. 

The disorder is encountered chiefly among men after puberty, and in 
those of all social conditions and grades of health. It is not transmis- 
sible by heredity. The mere performance of shaving is not known to 
produce it. At times the immediate cause of the disease is recognized 
when the upper lip is constantly irritated by a discharge due to profuse 
nasal catarrh. In other cases, again, all the causes of eczema may be 
invoked in explanation of the result. 

A careful study of many cases suggests that the hairs themselves are 
among the aggravating causes of the disease and the sources of its 
peculiar obstinacy. In health the motions of the free shaft of the hair 
do not irritate the follicle in which it is set ; in conditions of disease 
it is quite different. Each free hair operates like a lever upon the inflamed 
ring-tissue which encircles it on its escape from the follicle beneath, 
and thus by the touch of the hand, by the action of brushing, by cur- 
rents of air, or by any agency whatever, movement may be imparted 
to it. Every such movement teases to a variable degree the previously 
irritated surface beneath; and when estimate is made of the hundreds 
of such movements to which each hair is subjected during a period of 
twenty-four hours, the relative importance of this apparently insig- 
nificant factor may be appreciated. 

Pathology. — The disease is due to pyogenic cocci exciting an inflam- 
matory process, which, whether originally follicular or perifollicular 
in seat, may extend either toward or from the follicle. Sometimes 
extraction of the hair is followed by a drop of pure pus which exudes 
from the follicle, and the root-sheaths of the hairs are seen to be 
altered in consequence of the circumscribed follicular abscess. At 
other times the follicle itself is free from disease, and the exudative 
process has evidently expended itself upon the perifollicular or even the 
interfollicular tissues, in which case the papillary layer of the derma 
exhibits the usual phenomena of hyperemia, infiltration, and multipli- 
cation of protoplasm, with abundant vascular dilatation. 

According to Robinson, the disease always begins as a perifollicular 



COCCOGENOUS SYCOSIS. 279 

inflammation, under the influence of which transuded serum penetrates 
the follicle. Maceration and eventual destruction of the root-sheath of 
the hair result with the ultimate production of pus within and without 
the follicle. The pus when the hair remains in the follicle, finds its 
way to the surface by breaking through the epidermis near the hair ; 
occasionally exit is obtained between the shaft and the follicle-sheath. 

The hair-papilla usually escapes destruction, so that permanent 
alopecia seldom follows. The sebaceous glands are occasionally involved 
and even destroyed, but the coil-glands are affected in exceptional cases 
only. The hair, according to Unna, is closely encapsuled by horny 
cells which surround the neck of the hair-follicle, like a horse-collar. 
When pus is formed in the cutis, colonies of cocci spread from about 
the neck of the follicle into the cutaneous abscess and sometimes as 
deeply as the hypoderm. The cocci may also accumulate within the 
follicle. In total suppuration of the follicle the tightly packed cocci 
fill the hair-fissure, occupy the centre of the follicular abscess, and extend 
parallel to the skin on the under margin of the abscess. 

The micro-organisms recognized (by culture and reinfection) as the 
effective agents in the production of Tommasoli's bacillogenous sycosis 
were bacilli with rounded extremities presenting an elliptical or ovoid 
appearance. They measured 1.0 to 1.5 x 0.25 to 0.3 fi. The symptoms 
clinically resembled those of coccogenous sycosis. 

Diagnosis. — The most important consideration here is the distinction 
between the coccogenous and the hyphogenous diseases of the region of 
the beard, upon which point, naturally, the microscope finally decides. 
Still the clinical features of the two affections are quite distinct. The 
coccogenous form is recognized : (a) by the greater redness of the in- 
volved surface ; (6) by the extension of the disease in advanced cases to 
larger areas of symmetrical involvement ; (c) by the more superficial 
character of the lesions ; and (d) by the firm implantation of the hairs 
in their follicles in the earlier periods of the disease, their relative 
freedom in all cases from fracture, and the absence of stumps. The 
hyphogenous disease of the hairs is peculiar, in consequence of : (a) 
decidedly less redness of the surface attacked ; (b) the frequent limita- 
tion of the malady to a circumscribed area, or to several such, irregularly 
dispersed over a large region ; (c) the peculiar " lumpy, tubercular, 
nodular, and uneven " characters of the patch, upon which Duhring has 
laid significant emphasis ; and (cl) the earlier loosening of the hairs in 
their follicles, as also of the occurrence of fractured hairs and of stumps, 
exhibiting usually at the bulb unmistakable evidences of the nature of 
the disease. The malady is often mistaken for syphilis, chiefly on 
account of the un sightliness it produces ; but the pustular syphiloderm 
is very much less chronic in its course, is rarely limited for years to the 
face exclusively, and, when long persistent in one locality, is character- 
ized by ulceration and the production of very characteristic crusts. 

Eczema may complicate the coccogenous disease by preceding -or by 
following it, but typical instances of the two disorders may be recog- 
nized by the occurrence, in the case of eczema, of a discharging disease, 
not usually limited to the region of the beard, characterized by a more 
intense itching, and with marked absence of the papulo-tubercular lesions 



280 INFLAMMATIONS. 

described above. The lesions in eczema, moreover, are not invariably 
perforated by hairs. The shaven face affected with erythematous 
eczema is reddish in color, and desquamates, after full evolution of 
the disorder, without pustulation. 

Treatment. — In this form of sycosis the most effective treatment 
is radiotherapy. In eleven cases in which we have given the treat- 
ment a fair trial the lesions disappeared promptly. The technique is 
that recommended for acne, except that a harder tube is employed. 
The treatment is carried to the point of producing a. slight erythema 
and fall of the hair.- In the majority of cases from four to eight 
exposures suffice and the reaction subsides within six weeks. The hair 
returns usually in about two months. In one case of lupoid sycosis 
of seven years' duration the active lesions disappeared and the scars 
became much less conspicuous. 

In all cases of sycosis, except those treated by arrays, the essential 
and important step is the continued removal of the hairs which, as 
indicated above, are the chief sources of aggravation of the disease. 
This removal is accomplished best by epilation or by shaving, which, 
though often painful at the onset, soon is tolerated well by the 
sufferer. The majority of patients, however, object to the removal of 
the beard, far more on account of the consequent greater exposure to 
view of the un sightliness induced by the disease (then no longer partly 
masked by the hairs) than on account of the distress occasioned by 
the operation. To these objections there is but one response — the 
shaving is essential ; the deformity is relieved rapidly after its success- 
ful initiation ; the discomfort diminishes with each repetition of the 
process. For the disease in patients positively refusing to have the 
beard removed, whose cases are so severe as to require it, the practi- 
tioner will do well to decline to be responsible. There is no limit to 
the tedious and obstinate course of the malady in the one case, and in 
the other the results are speedily satisfactory, often in the course of a 
few weeks. 

When there is much tenderness, pain, swelling, pustulation, or crust- 
ing, the hairs may first be clipped short, and a bland poultice of oil, 
elm-bark, or of bread and milk applied. The practice in Vienna is to 
substitute for the poultice strips of soft muslin or linen spread with 
diachylon ointment, firmly bandaged over the cheeks, chin, or lips for 
from twelve to twenty-four hours, after which a razor is passed over the 
entire surface. The integument which thus becomes visible is usually 
a reddened infiltrated area, with pustules, papules, pustulo-papules, and 
some crusts dispersed here and there over it. After exit is given to all 
purulent collections this area is best treated by hot- water lotions, borated 
or alkalinized, and then a bland ointment is to be applied at night and 
a borated dusting-powder in the morning. Formalin lotions of the 
strength of 1 to 2 per cent, are valuable in all stages of the disorder. 
The subsequent treatment is largely that of eczema of equal grade of 
severity. In the more acute periods oleated lime-water, medicated w^ith 
calomel or with zinc oxide, ^ to 1 drachm (2.-4.) of either to the pint 
(512.), may often be employed with benefit ; or for this application may 
be substituted 2 ounces (64.) each of linseed-oil, Castile soap, and 



COCCOGENOTJS SYCOSIS. 281 

paraffin, to the pint (512.) of aqua calcis. Later, the Lassar paste or 
ointments may be used, particularly cold-cream salve, to which may be 
added either sulphur, zinc oxide, or, less preferably, one of the mercu- 
rials. Lotions of mercuric chloride, sulphur, alcohol, cologne-water, 
or iodated glycerin may be useful in stimulating indolent patches of 
infiltration. The treatment of these patches is indeed that of chronic 
eczema. 

Epilation is often essential for relief of the disease ; and in chronic 
cases severe methods have been employed, including the use of green 
soap, tar, and cauterization with acetic and even with nitric acid. Era- 
sion with the curette is to be named in the same category. These 
measures have been employed in aggravated cases ; but as the disease 
is certainly curable in a majority of patients without having recourse to 
these heroic methods, they are to be regarded in the light of a dernier 
ressort. It is not necessary in the majority of coccogenous forms of 
sycosis either to epilate or to employ caustics. By repeated and fre- 
quent use of hot borated water, formalin lotions, and the milder 
stimulants, with constant shaving, the desired result is usually 
within reach. Shaving should be continued for nearly a year after 
all traces of the disease have disappeared ; and it is a point of some 
importance to substitute for a fatty application a continuously applied 
borated powder as soon as the skin will tolerate the persistent use of 
the latter. 

Van Harlingen advises for acute cases a wash composed of ^ pint 
(256.) of rose-water, to which 1 drachm (4.) each of precipitated zinc 
carbonate and zinc oxide in powder have been added, with 2 drachms 
(8.) of glycerin and dilute liquor plumbi subacetatis. Veiel recom- 
mends a solution of pyrogallol (1 part to 50) for painting over the 
region affected, followed in the day by emollient cataplasms and in the 
night by diachylon or weak tannin ointments. Sycosis of other por- 
tions of the body is to be treated as described for the region of the 
beard. 

Internally, treatment, when indicated, should be of the kind de- 
manded by the condition of the patient. It is a matter worthy of 
special attention, however to purge every previously treated case of 
suspicion of artificial element, by withdrawing for a time all internal 
medication. The disease is so disfiguring that many patients swallow 
potassium iodide, arsenic, and other deleterious drugs for months before 
consulting one who is wiser than they in these matters. Exposure of 
the face to dust, smoke, wind, and other sources of irritation should for 
a time be avoided. 

In the hygienic management of these cases all use of tobacco and 
alcoholic beverages is to be abandoned. Even the drinking of hot 
tea, coffee, and stimulating beverages of other kinds is to be inter- 
dicted. The diet should be of the simple character recommended in 
eczema. Inasmuch as many patients suffer from a coincident nasal 
catarrh, hot baths should be exchanged for daily cold sponging of the 
body-surface, for patients able to endure the shock, followed by brisk 
friction with flesh-brush or with coarse towels. 

In acute cases it may be desirable to begin treatment with a brisk 



282 INFLAMMATIONS. 

mercurial cathartic ; the alkaline diuretics advised by authors will, at 
least, do no harm if judiciously employed. The same may be said of 
calx sulphurata and minute doses of calomel in the pustular stages of 
the affection. But in other cases cod-liver oil and iron are demanded 
by the general condition of the patient, usually one of the class ex- 
hibiting the evidences of " hospitalism." No firm believer in the 
coccogenous etiology of the disorder will, however, expect by these 
measures alone to relieve the disease. 

Prognosis. — The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or greatly be improved 
by judicious treatment. The latter requires the personal supervision 
of the physician and close attention to details. 

In exceptional cases the disorder is exceedingly chronic and obsti- 
nate, and requires perseverance on the part of both physician and 
patient to attain the desired end. Relapses are of frequent occurrence, 
due usually to neglect of asepsis after apparent recovery. In a few 
very rare cases (lupoid sycosis, tuberculosis) there is cicatricial tissue 
left after repair. 

IMPETIGO. 

(Lat. impetere, to rush upon. ) 

(Ger., Eiterflechte ; Fr., Impetigo, Dartre humide.) 

The researches of Bockhart and others have demonstrated that 
the symptoms once designated by the term " impetigo/' as also those 
of furunculosis and sycosis, are simply the local results of infection 
wirh staphylococci and streptococci. The symptoms to which in dif- 
ferent cases these several names are given differ in consequence of the 
accidents of location, the sex of the patient, and the opportunities for 
extension of the disease. 

Hebra stated that, even in his day, the pustular cutaneous affection 
described by authors under the name " impetigo " had no existence as 
an independent disease. Unquestionably a long list of disorders hith- 
erto described under this term included, in fact, forms of pustular 
dermatitis. The reasons for retaining the name given above and for 
assigning to it certain peculiar eruptive features are based upon the 
simple fact that the lesions displayed, probably in consequence of the 
operation in a similar way of like causes, reproduce themselves again 
and again, so as to exhibit the same clinical picture in different patients. 
The convenience of the name impetigo, as descriptive of a group of 
cutaneous symptoms, is therefore the sole reason for its retention. 
There is, however, among some dermatologists of the French school 
a tendency to consider impetigo a distinct disease and to distinguish 
several forms, each having a definite cause and capable of reproducing 
itself through inoculation. 

Symptoms. — The disease is not infrequently encountered, being 
observed chiefly in children and young adults of both sexes, though 
typical symptoms may be exhibited at any period of life. In such 
patients, from one to twenty or more isolated and often widely separated 
minute vesicles or vesico-pustules, superficial, without areolae, without 



IMPETIGO. 



283 



induration, and usually acuminate, appear upon the skin-surfaee either 
simultaneously or in rapid succession occasionally after a slight access 
of fever. They are speedily transformed into split-pea-sized or larger, 
circumscribed, oval or circular pustules, so rapidly transformed, in fact, 
that often the early vesicular phase is not manifest, the lesions showing 
as minute pustules from the first. When fully developed they are 
globular, yellowish white in color, discrete, well distended with their 
puriform, rarely bloody contents, and projected clearly from the surface 
on which they rest. They may be surrounded by an erythematous 
areola, or simply be superimposed upon an integument of unaltered color. 



Fig. 46. 




Staphylococcia, superficial type. 

They may persist as pustules, or may burst, their contents drying into 
a yellowish crust resembling honey, or into brownish-tinted concretions 
which adhere with firmness to the superficial and circumscribed base, 
where a slight weeping can be determined. They run an acute course, 
usually terminating within a fortnight. They are much more commonly 
observed upon the face, but are recognized elsewhere, always sparsely 
upon the trunk and extremities. The eruption is never in any sense 
generalized, its characteristic feature being the fewness of the lesions, 



284 INFLAMMATIONS. 

which are scarcely ever grouped, and which occur in capriciously 
selected locations. The subjective sensations are slight, and the erup- 
tion is more often picked than scratched. The disease bears no relation 
to pustular eczema. It is common in dispensary and hospital patients, 
and since these are often the victims of neglect and the subjects of vices 
of nutrition it has been considered the appanage of scrofula. But the 
disease is also encountered in well-nourished and rosy-cheeked chil- 
dren ; in the latter, when well cared for, the eruption proceeds regularly 
to resolution, while in the former it is prolonged and often aggravated, 
thus attracting to a greater degree the attention of the physician. The 
pustules are never umbilicated, never seated upon ulcers, and are never 
followed by cicatrices. 

Impetigo Contagiosa (Porrigo Larvalis, Porrigo Contagiosa, 
Pemphigus Acutus Contagiosus Adultorum (Pontoppidan), Im- 
petigo Contagiosa Bullosa). — In 1862 Tilbury Fox gave the name 
impetigo contagiosa to a group of symptoms which were by him sup- 
posed to be characteristic of a definite disease. These lesions are now 
recognized as those of impetigo. The disorder is essentially a finger- 
nail-filth disease, the eruptive symptoms being limited to regions often 
attacked by the fingers with filth beneath the nails. 

The eruption, occurring in infancy, childhood, and early adult life, 
may be preceded by a febrile process, and appears in the form of rarely 
numerous, isolated, simultaneously or successively developed vesicles, 
vesico-pustules, pustules, or bullae, usually about the face, but also upon 
the neck, the buttocks, the hands, or the feet. In severe cases these 
lesions are surrounded by an areola. The lesions are roundish, flat, 
have the average size of that of a split pea, are filled with thin sero- 
purulent or distinctly purulent contents, and become covered in the 
course of a few days with dry, granular, straw-colored crusts which 
adhere to the slightly reddened base on which they rest. Often 
the crusts seem to be pasted to the surface ; in many cases the free 
edges of the crust seems to be in part curled up from the underlying 
integument. Beneath the crusts are to be discovered very super- 
ficial erosions which rapidly become covered with epidermis. They 
occasionally coalesce, and their complete involution requires from a 
week to a fortnight. When they are of the dimensions of bullae a 
pseudo-umbilication may be observed at the apex, produced solely by 
flaccidity of the roof-wall, which is never " guyed " down, as in variola. 
The contents of the lesions are inoculable and auto-inoculable, the dis- 
ease thus spreading from one member of a family to another, and also 
from one part of the body of an individual to another part. The 
mucous surfaces are occasionally invaded (impetiginous stomatitis). The 
subjective sensations are mild, the itching rarely being severe. The 
disease runs a tolerably definite course, being usually at an end in a 
fortnight ; it may recur. It may be, Kaposi states that it is at all 
times, accompanied by submaxillary adenopathy. 

Impetigo may be indicative of the symptoms of several widely dif- 
fering causes, all resulting in a coccogenous or hyphogeneous disorder. 
In some cases the irritation is set up by the encroachments of the tricho- 



IMPETIGO. 285 

phyton. In otLer cases there are pediculi of the occipital region, and 
the scratching set np in children in consequence of attacks of lice fur- 
nishes the opportunity for infection with staphylococci. In yet other 
cases the micro-organisms responsible for varicella have operated to 
produce the symptoms. 

The several clinical pictures differ on account of the greater or lesser 
diffusion of the contagious elements in each case ; for example, there 
may be a few isolated pea-sized and larger vesico-pustules on a single 
hand ; or many may be clustered about the mouth and lips ; or dense 
greenish crusts may succeed such lesions over occiput or scalp ; or 
there may be much larger pustulo-bullous elements over the legs, torn, 
scratched, and thickly crusted or covered with hemorrhagic incrusta- 
tions. In rare instances circinate, annular, gyrate, serpiginous, herpetic, 
variolaform, and even pustulo-crustaceous lesions have been observed. 
The disorder is not often seen in private practice, but in public patients 
it occurs among the cachectic, the filthy, and the neglected. The 
several types of impetigo described as staphylogenes, streptogenes, 
circinata, etc., have no distinction of symptoms. 

Etiology, — The cause of impetigo is the transmission by the 
medium of finger-nail-filth of a mixed infection with streptococci 
and staphylococci ; often the one is grafted upon the other. The 
peculiarities of the cocci are the shortness of their chains, the slightness 
of their incurvations, their failure to interlace, and the irregular form 
of the elements of which the chains are composed. For these reasons 
an attempt has been made to disassociate, without result thus far, the 
germs of this disease from those found in the pus of other affections. 

The disease occurs rather at the age of childhood than in infancy and 
adult life, a period when the hands are first brought into habitual con- 
tact with the face, these quite suggestively being the sites of election. 
The lesions are rarely scratched, being more often torn with the nails in 
picking, so that the crusts may be somewhat blood-colored. The prac- 
tice of picking the nose and other parts of the face and the body Avith 
unwashed hands is the chief source of mischief. In later life the habit 
of refraining from carrying the hands to the face w T hen the former are 
soiled becomes instinctive. Before this instinct is well established — that 
is, in childhood — the hands will convey to the head any particle of filth 
or of dust with which they may have been brought in contact. 

The somewhat obscure relations of the disease to varicella, variola, 
and other affections occurring in epidemic visitations have attracted 
the attention of many observers. The disease is one peculiarly prone 
to attack children and those in the humbler grades of life. 

The eruption often occurs during convalescence from a more or less 
actively contagious disease. The antecedence of some fever in many 
cases is admitted by all observers. Duhring and Fox have seen it 
follow vaccinia, and the former admits that some connection between 
the two seems probable. It may occur typically in a series of children, 
each of whom is convalescent from varicella. 

Pathology. — The lesions have been examined microscopically by 
Bockhart and others, who have thus been able to establish clearly the 
coccogenous origin of the disorder. Plainly, each lesion is but a dis- 



286 INFLAMMATIONS. 

tinctly circumscribed and superficial pea- to bean-sized abscess, situated 
between the intact corneous and the prickle-layers of the skin. Balzer 
and Griffon 1 agree with Thibierge and Bezancon in asserting that almost 
without exception the lesions of impetigo and ecthyma contain strepto- 
cocci and no staphylococci. In some cases, however, the staphylococcus 
pyogenes aureus and albus are present. 2 Larier and other French der- 
matologists describe an impetigo strepto-coccogenata circinata, in which 
the lesions closely resemble those of herpes iris, and in which the strep- 
tococcus only is found. Leroux and others, recognizing the fact* that 
many micro-organisms similar in external appearanee have decidedly 
different potentialities, have suggested that the streptococci responsible 
for the several clinical pictures of impetigo may differ in effect. 
Sabouraud 3 has demonstrated that the streptococcus usually present 
is disguised by the rapidity of development of the staphylococci com- 
monly recognized. 

In Unna's differential diagnosis of the impetigo- and eczema-pustule 
stress is laid upon the sero-purulent character of the contents of the 
latter, the dissemination of cocci throughout the lesion, the softening 
of the corneous layer in places, and the occurrence of morococci free 
and within the leucocytes. In impetigo the staphylococci are clustered, 
are extracellular, are relatively small, and are clustered beneath the 
intact roof-wall of the lesion. 

Dewevre 4 reports a number of successful inoculations and auto-inoc- 
ulations practised with the contents of the vesico-pustule, with finely 
powdered impetiginous crusts, and with the products of scraping the 
subjacent erosion. In 1884 one of us succeeded in producing an 
almost typical vesico-pustule upon the left forearm by inoculation (all 
due precautions being observed) with the moistened debris of crusts. 
This inoculation was done in the clinic, the crusts being taken from 
typical lesions upon the face of a young girl inoculated while under 
observation from the lesions of exactly similar character on the face of 
her twin sister. The lesions on the forearm produced a characteristic 
crust which in seven days was also used for inoculation of two students 
then present at the clinic, in one of whom there was no result, and in 
the other an abortive lesion. 

The disease is contagious, and its lesions inoculable and auto-inocu- 
lable, whether as a coccogenous or hyphogenous process. 

Diagnosis. — To establish the identity of this affection it is neces- 
sary to define its exact differences from eczema pustulosum. These 
differences are : first, the absence of infiltration of the tissues affected ; 
second, the absence of itching; third, the failure of the lesions to form 
patches ; fourth, the isolation and wide separation from one another of 
lesions distinctly pustular ; fifth, the large development and rather per- 
sistent character of the pustules; sixth, the evident termination of the 
disease, which does not, as does eczema in many cases, progress to form 

1 La Presse med., 1897, lix., p. 130. 

2 Cf. Engman, Jour. Cutan. Dis., 1901, xix., p. 180. 

3 Annales, 1900, s. 4, i., pp. 62 and 320 (report of his researches and review of 
literature )o 

4 Arch, de Med. et de Pharm. mil., 1885, vi., p. 210. 



ECTHYMA. 287 

a freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct morbid process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema which 
is often originated by less irritating causes. 

In ecthyma the pustules are in appearance much more formidable 
than those of impetigo in consequence of their size, depth, inflamma- 
tory base, areola, flat hard bulky crust, and erosive action upon the 
skin. 

In varicella the lesions are small, much more widely distributed 
over the body, and are vesicular only, rarely bullous. In pemphigus 
and herpes iris the seat, character, and period of evolution of the lesions 
suffice to establish the diagnosis. 

Treatment. — Individual pustules are to be opened with an aseptic 
comedo-needle ; the purulent contents gently removed by washing with 
borated water ; and the floor smeared with any mild ointment, such as 
5 grains to \ scruple (0.33-0.66) of ammoniated mercury to the ounce 
(32.) of cold-cream salve, or bismuth subnitrate J drachm (2.) to the 
ounce (32.), or benzoated zinc salve. Van Harlingen recommends the 
application of a salve on bits of muslin, covering the whole with waxed 
paper. A dusting-powder containing calomel may be substituted for 
the salve or be employed afterward. The disease tends to spontaneous 
recovery if the lesions be not irritated. When they are situated within 
reach of a child's tongue which is constantly thrust out to moisten them, 
they may linger obstinately and require protection by flexile collodion. 



ECTHYMA. 

(Gr. €Kdvjua } a pustule ; kudvu, I burn out.) 

(Ger., Ekthyma, Eiteeblase.) 

The term " ecthyma," like several of the titles of chapters imme- 
diately preceding, no longer points to a distinct disease. It represents 
rather a tolerably definite group of symptoms readily separable clin- 
ically from other affections produced by different causes. The most 
common cause is infection of the skin of the lower extremities with 
pus-cocci after scratching ; then follow traumatisms, primary and 
secondary, associated with pediculi of the body (pediculus vestimenti), 
and combinations of these with bedbug-bites ; general filthiness of 
the person and clothing of body and bed ; and the cachexia of most 
patients in these conditions. The term ecthyma is, however, not 
to be discarded, as it suggests to the mind not merely these com- 
posite etiological factors, but the picture in the skin produced as 
a result. 

The disease is characterized by the occurrence of one or of several 
minute vesicles filled with clear serum, which soon become changed 
to circumscribed, yellowish-gray, reddish or dark-livid, roundish, bean- 
to filbert-sized pustules, which are the result of a distinctly circum- 
scribed inflammatory process, limited to the base of each lesion 



288 INFLAMMATIONS. 

or extending from it at the periphery in a diminishing hyperemia. 
This process is distinguished by the formation at the base of the pus- 
tule of an indurated phlegmon, which is converted into a loss of tissue 
involving in mild cases the superficial, in severe grades the deeper, por- 
tions of the corium. The purulent or sanguinolent contents of the 
lesions dry in dark-colored, thick, rough, adherent crusts, the color 
being somewhat dependent upon the quantity of blood with which 
they are commingled. On removal of this concretion a minute, 
shallow, circular pit is discovered, invading the true skin to various 
depths, and lined with a tenacious, puriform, and often blood-stained 
product. When carefully wiped clean this solution of continuity, 
which really constitutes a minute ulcer, is seen to have a floor reddish 
or grayish in color and indolently granulating. Both superficial and 
deep-seated types of the disease are recognized with a single ulcer or 
exceedingly numerous areas of ulceration resulting. 

The pustules may be acutely or indolently developed, and, when 
multiple, be coincident or successive. They occasion rather a sensa- 
tion of heat, burning, and pain than of itching, the latter being usually 
more distinct when the lesions are healing under their crusts. Their 
formation may be preceded by mild general pyrexia. They occur at 
all ages and in both sexes, usually upon the extremities, and also upon 
every portion of the body. 

The deeper lesions are followed by pigmentation and persistent 
punctate or larger cicatrices. The entire course of the disease occupies 
about two weeks. The subjective phenomena are a sense of heat, 
burning, pain, and soreness. There may be accompanying lymphangitis 
or adenopathy. 

Etiology. — The pyogenic cocci (in particular streptococci) are the 
efficient causes of most of the lesions ; practically the agents capable 
of producing eczema and dermatitis (traumatism, heat, scratching, para- 
sites, etc.) either effectively operate or influence to a morbid degree the 
subjects of other diseases, such as anaemia, asthenia, struma, variola- 
convalescence, and menstrual disorders. Filth and neglect are most 
common aggravations ; in other words, that circumscribed cutaneous 
ulcer will be the angrier and the deeper which occurs in the victim 
of any depressing disease whose skin is scratched with nails begrimed 
with dirt, and is covered with the products of the excretory processes. 
The pus thus produced is in various degrees inoculable and auto- 
inoculable, as is the product of many inflammatory processes of similar 
grade. 

Pathology. — In many cases of ecthyma there has been demonstrated 
a streptococcic infection of the skin, usually with but few chains of 
micro-organisms visible on bacteriological examination. The pustule 
of the disease differs from the pustule of eczema or the pustule of im- 
petigo in the severity of the exudative process by which it is produced, 
and in its limitation to the exact seat of external irritation. By the 
extension of that process to the corium there is an actual loss of some 
of the elements constituting the papillary layer, the result often being 
a cicatrix which contracts as it grows older, and which is, in milder 
cases, finally barely visible as a minute cicatriform punctum. One who 



ECTHYMA. 289 

frequently examines the skin of the entire body with care can usually 
detect the ancient sites of these lesions by their indelible though insig- 
nificant relics. 

According to Unna, the ecthyma-pustule, as distinguished from that 
of impetigo, is less an epidermal abscess than a result of epidermal 
inflammation, fibrinous at the centre and exceedingly cedematous at the 
periphery. The crust contains fibrin and epidermal layers. 

Sabouraud points out that the original streptococcic infection is 
often succeeded by a secondary microbian involvement whereby the 
staphylococci present are enabled to produce the peripheral lesions of 
impetigo, furunculosis, etc. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction between 
them is largely artificial and based upon the severity of the inflamma- 
tory process, there is small danger in consequence. Kaposi expresses 
the truth in his suggestion that there can be but little objection to the 
employment of the term ecthyma when it is desired to characterize pre- 
cisely the pustular grade of any cutaneous inflammation at a given time. 
The pustules of variola are " ecthymaform," and many of those seen 
in syphilis exhibit similar characters ; but the history of the general 
affection should throw light upon the identity of the cutaneous disease. 
In syphilis, moreover, the ulceration at the base of the lesion exhibits 
the pronounced features of the syphilitic ulcer in its secretion, floor, 
edges, base, crust, and career. The crust, in particular, of the flat 
pustular syphiloderm has the rupioid conical appearance which sug- 
gests the shell of the oyster, and the underlying ulcer is larger and 
deeper than in ecthyma. In the furuncle there is usually a central 
core; in impetigo the pustules are not deep-seated, and there is no 
ulceration at the base; the crust is superficial, yellowish, firmly ad- 
herent, and the lesions are more numerous. 

Treatment. — The general treatment of patients affected with 
ecthyma is a matter of importance. A proper regulation of the food 
and hygienic surroundings is not to be neglected. Tonics are fre- 
quently indispensable, including iron, quinine, and strychnine. The 
destruction of any pediculi and the cleansing of the skin with soap and 
water will often be sufficient to effect a great change. This fact is 
well illustrated in hospital practice, where young patients rapidly im- 
prove after a bath, followed by inunction with vaselin, and a few sub- 
stantial meals of a nutritious character. When the lesions are abun- 
dant the treatment is in general that of pustular eczema. Crusts are to 
be removed after soakings with oil or fat ; and the floors of the former 
pustules, after washing with carbolated water, should be dressed with 
an ointment containing from 10 to 15 grains (0.666-1.) of mercuric 
ammonio-chloride to the ounce (32.) of lard. If the minute basal ulcers 
are sluggish, they may, after careful cleansing, be touched with a small 
swab that has been dipped in a 0.5 per cent, formalin solution or in a 
solution of mercuric chloride in tincture of benzoin, 1 grain (0.066) to 
the ounce (32.). Carbolic or boric acid or iodoform may be employed 
for the same purpose. For the salve mentioned above may be substi- 
tuted one containing 10 grains (0.66) of calomel, or J drachm (2.) of 
bismuth subnitrate to the ounce of salve-basis. 

19 



290 INFLAMMATIONS. 

In every case of the disease it is desirable to inquire whether any 
medicines have been ingested prior to the appearance of the eruption, 
since these may be responsible for the lesions. 

The Prognosis is always favorable. 



CONGLOMERATIVE PUSTULAR PERIFOLLICULITIS. 

Leloir l gave this name to an eruption which he described as appear- 
ing on the backs of the hands and buttocks and occasionally on other 
parts of the body. 

The disease begins by the appearance of a round or oval, somewhat 
elevated, reddened or purplish plaque, with definite outlines. The 
plaque may be no larger than a dime, or it may be of the size of a large 
coin or larger, and may be elevated a quarter of an inch above the 
general level of the skin. Its surface is smooth or mammi Hated and 
is perforated by numerous follicular openings from which pus or dried 
plugs resembling comedones may be expressed. The openings of some 
of the follicles may be covered by unruptured pustules. Later, the 
patch becomes more phlegmonous, fluctuation can be detected, the fol- 
licles are more patulous, and pus in large quantity can be expressed. 
The whole then has much the appearance of a kerion of the scalp or 
of a flat carbuncle. 

There is usually but one such plaque, though there may be two or 
three, rarely more. Subjective sensations are slight, though there is 
usually some itching and burning. There is no systemic disturbance. 
The disease runs a rapid course, requiring about a week in which to 
develop, after which it remains stationary for a week or two, and then 
disappears under appropriate treatment in from ten to fifteen days. 
More or less deep pigmentation remains some time after the lesions 
heal, but there is no ulceration and in the few cases in which scars are 
left they are usually very superficial. 

Folliculitis and Perifolliculitis. — Quinquaud and Pallier 2 
describe a follicular disease which is chronic, becomes papillomatous, 
and is very stubborn under treatment. Besnier and Doyon 3 enumerate, 
in all, five varieties of the disease, including two pseudo-ulcerative, 
serpiginous, and virulent forms which resemble anatomical tubercle. 

Etiology. — These disorders are probably due to contagion, and 
are seen most frequently in those who work among horses and other 
animals. 

Pathology. — The process is an inflammation of the follicles, peri- 
follicular tissues, and sebaceous glands. Leloir found several forms 
of micrococci and zooglcea in the pus, but he failed to reproduce the 
disease by inoculation-experiments. Quinquaud and Pallier believe 
the active agent to be staphylococcus pyogenes albus, which acci- 

1 Annales, 1884, v., p. 437 (with plates). 

2 Des perif'ollicultes suppurees agminees en placards." These de Paris, 1889. 

3 Kaposi : Besnier-Doyon, vol. i., p. 795. 






HERPES SIMPLEX. 291 

dentally obtains entrance to the follicles and glands. Sabouraud found 
in several cases a large-spored trichophyton. 

Treatment. — The treatment is purely local. In the usual milder 
forms daily evacuation of pus, hot boric-acid fomentations, or frequent 
hot bathing, with antiseptic dressings, constitute the only treatment 
necessary. In stubborn forms stimulating treatment by means of 
strong solutions of silver nitrate or of carbolic acid, or by means of the 
actual cautery, may be indicated. Occasionally it will be necessary to 
remove the growth with a curette. 

HERPES SIMPLEX. 

(Gr. e pttf.lv, to creep.) 

(Fr., Dartre; Ger., Flechte, Blaschenflechte.) 

The term " herpes " is responsible for much of the confusion which 
has existed with respect to cutaneous diseases. By the ancients it was 
employed, as its etymology suggests, to designate a disease creeping or 
extending gradually over the surface or within the substance of the 
skin. By several more modern authors the term is employed in a 
generic sense in a futile attempt to distinguish a series of so-called 
" herpetic diseases," and even herpetic diatheses from those of a different 
complexion. The significance which attaches to the word in the minds 
of dermatological authors of to-day is exceedingly simple, and is limited 
to the conditions described in the following paragraphs. Herpes zoster, 
though closely related to other types of herpes, is recognized as a dis- 
tinct disease, and in this work is considered separately. 

Symptoms. — The disease is declared by the occurrence of millet- 
seed- to coffee-bean-sized vesicles (single or relatively few in number, 
and in the latter case grouped), which may be preceded or accom- 
panied by a general febrile process, though in many cases there is no 
constitutional disturbance. The vesicles are usually displayed sym- 
metrically, are short-lived, surviving but for a few hours, and are filled 
with a clear serous fluid which may become lactescent. After acci- 
dental or spontaneous rupture there is left a slightly tumid superficial 
excoriation, which is covered frequently by a light crust and at times 
is characterized by circumscribed hyperemia, slight infiltration, or 
oedema of the base and periphery. The lesions rarely persist for more 
than a few days, and leave no permanent pigmentation or scar, unless 
complicated by pus-infection. The subjective sensations are not usually 
severe ; they include moderate pain, itching, and heat. 

Herpes Facialis, Herpes Febrilis, Herpes Labialis, " Cold-sores." — 
About the lips, the mouth, the cheeks, and the alse of the nose, more 
rarely upon other portions of the face, lesions occur singly or in groups, 
possessing the characters described above. Their occurrence is usually 
sudden. Their frequency about the lips has suggested one of the titles 
under which they are most often described by authors. The tongue, 
the buccal membrane, the palate, and the larynx may participate in the 
morbid process; the lesions in such moist situations being represented 
by isolated or by grouped dark-grayish patches of epithelium that are 



292 



INFLAMMA TIONS. 



sensitive and exfoliate. The functions of the mouth in articulation and 
mastication are thus rendered painful. Often the lesions coalesce, form- 
ing in an irregular line of elevated epidermis a pea-sized bleb, spread 
along the vermilion border of the lip and distended with clear serum. 
The burning and itching sensations which accompany the lesions are 
often marked and distressing. In the course of two or three days thin 
crusts form, the exfoliation of which terminates the disorder. The dis- 
ease is common in acute pneumonia and in malarial and enteric fevers. 
In these cases, as Kaposi has shown, the occurrence of the eruption by 
no means augurs favorably in every instance, as, nevertheless, a fatal 
result may follow. The connection between labial herpes and rigors 
has long been recognized, though particular attention has been directed 
to this relation by Hutchinson and Symonds. Trophic disturbances, 
traumatism, exposure to solar heat, unusual fatigue, a simple coryza, 
exposure to a draught of cold air, and temporary gastric disorders may 
suffice to induce the disease. There are patients who can produce the 
lesions at will by tickling the lips with a feather, and in some indi- 
viduals there is an exquisite susceptibility to the disease. The dis- 
order is always short-lived though often recurrent, and the superficial 
crusts which terminate the process are never followed by scars. Sym- 
mers, of Aberdeen, successfully cultivated a rod- or thread-shaped 
micro-organism (solid, filamentous, and without septa) obtained from 
the lymph in vesicles of herpes labialis. 

Labial herpes should not be confounded with the symptoms of La 
Perleche, described on another page. The disease to which the last 
name has been given in France is due to a parasite. 

Epidemic Herpetic Fever, which has been observed by Savage l and 
others, has prevailed in institutions in which young subjects are con- 
gregated. There are usually rigor, high fever, a coated tongue, adenop- 
athy, and a vesicular rash over the face. 

The Generalized Herpes of French authors has been rarely seen in 
this country. 

Herpes Progenitalis (Herpes Genitalis, Herpes Pr^putialis) is 
characterized by the appearance of one or a group of transitory vesicles, 
in men on the inner face of the prepuce, especially upon its upper limb, 
on the glans, on the balano-preputial sulcus, or in the adjacent integu- 
ment; in women, on the hood of the clitoris, the labia minora, the 
inner face of the labia majora, or adjacent surfaces even as far removed 
as the buttocks. 

The disorder is seen most frequently in young adults and in early 
middle life, its occurrence after the age of fifty being unusual. There 
is commonly a precedent pruritus or a sensation of heat, sometimes 
very considerable pain, followed by the appearance of one or of several 
pinhead-sized vesicles seated upon a tumid and hypera^mic base. Within 
the preputial sac the lesions may either rupture at an early moment or 
assume the features above described as presented upon the mucous 
1 Jour. Cutan. Dis., 1883, i., p. 253. 



HERPES SIMPLEX. 293 

membrane of the mouth. The resulting oedema of the prepuce is often 
displayed in an annular tumefaction encircling the glans, while the labia 
minora perceptibly project from the general vulvar, plane. In these 
localities the floors of ruptured vesicles are particularly liable to be 
irritated (coitus, caustic, etc.), and then pus and even blood may be 
exuded with much angrier excoriation and the resulting crusts be of 
darker shade. In the course of a few days even these crusts fall, and 
the disease is at an end. Successive crops of vesicles, however, may 
prolong the disorder for several weeks. Recurrence is common. 

Rarely, a first attack of herpes in man results in an extraordinary 
sensitiveness of the balano-preputial membrane that persists for more 
than a year. The patients are often middle-aged men, married, and 
virgin as to venereal antecedents. The membrane becomes tumid, tense, 
slightly glazed, and dark red to dark purple in hue. Upon any undue 
sliding of the prepuce over the glans there occurs a very superficial 
fissure, whence a drop of serum oozes. The membrane becomes so 
sensitive that the passage of the finger over it is resented as though the 
conjunctiva had been touched. Unusual friction by the clothing or the 
use of a stimulating lotion is followed by intense pain and aggravation 
of symptoms, and the price of coitus is several days' rest in bed. 

Naturally, the diagnosis of herpes progenitalis is between chancroid 
and chancre. The latter will be manifested by its induration, its period 
of incubation, and its characteristic inguinal adenopathy. The chan- 
croid, whether in pustular form or as an inoculated abrasion, is ab 
origine ulcerative in tendency, capable of auto-inoculation, and often 
accompanied by sympathetic, inflammatory, or virulent bubo of one side. 
Balanitis, with its puriform secretion and superficial patches of reddened 
epithelium, is readily distinguished from herpes progenitalis by its 
symptoms, though the two disorders frequently coexist. 

The practitioner should never forget that the patient who exhibits a 
herpes of the genital region to-day may have been inoculated at the site 
of the lesion, which to-morrow or later may take on the chancrous 
modification. The rule to be followed, then, is very simple. No 
individual with progenital herpes can be assured of immunity against 
syphilis until the longest period of incubation of the syphilitic chancre 
has elapsed since the date of the last suspected exposure. 

Herpes progenitalis is almost universally the result of naturally or 
unnaturally induced sexual erethism or of congestion of the genitals 
from other causes. Its occurrence in an individual virgin as to such 
antecedents may be due to the causes efficient in the production of her- 
pes facialis. In unusually sensitive persons it may be associated with 
dyspepsia, constipation, and the phenomena of the gouty state. It may 
follow any of the venereal diseases ; or may be induced simply by filth. 
Though relatively rare in chaste women, it is of common occurrence in 
prostitutes. In some women it frequently accompanies menstruation 
(Herpes Menstrualis). 

Diday and Doyon l believe that true herpes of the genital region is 
always of recurrent type, and well marked by its special course, career, 
and consequences. All others of a false type are divided by them into 
1 Les Herpes genitaux, Paris, 1886. 



294 INFLAMMATIONS. 

(1) an irritative form, seen in women as the result of vaginal discharges, 
sexual irritation, etc. ; (2) a pseudo-membranous or diphtheroid form, 
also occurring for the most part in women, presenting vesicular and 
even bullous lesions the rupture of which is the signal for pseudo- 
membranous transformation ; and (3) a neuralgic form, which is merely 
zoster of the genital region. 

Pathology. — The eruptive phenomena are due to irritation of the 
nerves either directly or through reflex excitation. There is in many 
(probably in all) cases a localized peripheral neuritis of brief duration, 
involving the superficial nerves. The possibility of a microbic origin 
has been suggested. 

Treatment. — The milder forms of herpes occurring about the lips 
and the genitalia require the simplest treatment. Sponging with pure 
water as hot as can comfortably be tolerated is often of value if fol- 
lowed by the local application of a weak lead solution, spirit of cam- 
phor, or solution of zinc sulphate 1 to 6 grains (0.066-0.40) to the 
ounce (30.). Alcohol or spirit of camphor applied locally will some- 
times abort the disease. Equal parts of tincture of benzoin, alcohol, 
and glycerin is an effective combination. Duhring recommends highly 
the following : 

K f£T5&J «bhs; 1-33-4 

Alcohol., 3j ; 4 

Aquse dest. , £ vij ; 28 M. 

Sig. Shake and apply freely and frequently. 

Bleuler states that a 1 per cent, ointment of cocaine gives prompt 
relief and shortens the course of the disease. On the lips, after rupt- 
ure of the vesicles, the abraded surface may be protected by frequent 
applications of the compound tincture of benzoin. Crusts may be 
removed by the use of simple ointments, to which tincture of benzoin, 
1 drachm (4.) to the ounce (30.), may be added with advantage. For 
lesions at some distance from the mucous surfaces, dn sting-powders 
sometimes give relief; or if the lesions be few in number and be seen 
before rupture of the vesicles, the latter may be sealed completely 
over with several layers of collodion, beneath which the lesions rapidly 
dry and disappear. 

Occurring upon the genital region, the lesions are to be protected 
by the interposition of a pledget of lint, or a borated or salicylated 
dusting-powder. As a rule, ointments are unsuited for the moist 
mucous surface of the genitals, the malodorous emanations from moist 
diseases of such parts being retained by all grease-containing com- 
pounds. Lotions answer far better, and they may be made stimulant 
with alcohol ; astringent with tannin, zinc sulphate, or cupric sulphate ; 
anodyne with opium or cocaine ; and antiseptic with formalin, carbolic 
acid, or corrosive sublimate. Prophylaxis by the local use of aromatic 
wine, or tannin and brandy, with a sexual hygiene that will prevent 
congestion of the genitals, is a matter of importance. In cases in which 
recurrences continue it is necessary to investigate the general health 



HERPES ZOSTER. 295 

of the patient and correct whatever defects may be found. Arsenic is 
occasionally of value in preventing recurrences. 

HERPES ZOSTER. 1 

(Gr. ^coctt/Pj a girdle; Lat. cinguhm, a girdle.) 

(Shingles, Zoster, Ignis Sacer, Hemizona. Ger., Gurtel- 

FLECHTE, GuRTELAUSSCHLAG ; Fr., ZONA.) 

Symptoms. — The eruption in this affection usually is preceded, for 
a period lasting from a few hours to days and even weeks, by hyper- 
esthesia and neuralgic sensations of moderate or of severe intensity. 
These sensations usually are limited to the area of the integument 
subsequently or coincidently displaying cutaneous lesions ; but there are 
exceptions to this rule, as at times the pains are experienced elsewhere. 
Often, though limited to the region about to be attacked, the pain 
occurs where it is experienced in other neuralgias, at the points indicated 
by Romberg as corresponding with regions in which cutaneous branches 
are given off by the nerve-trunks. There may be mild constitutional 
disturbance in the form of malaise or febrile symptoms. Adenopathy 
occurs frequently in the neighborhood of the eruption, and may be 
generalized. 

The lesions of zoster are arranged in from two to a dozen or more 
irregularly shaped groups, commonly along the cutaneous distribution 
of a single nerve. These groups are separated by areas of normal 
integument, show little tendency to coalesce, and may be widely scat- 
tered. Aside from the few exceptions which prove the rule, zoster 
occurs but once in the lifetime of an individual, and is limited to one 
side of the body. 

According to Fabre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease 
that appears in the form of brilliant or dull-red, poorly defined, erythem- 
atous macules, groups of which appear in the tract supplied by the 
affected nerve. As the patient rarely presents himself for treatment 
until after the appearance of vesicles, the macules usually escape 
observation, either having disappeared or being overlooked. The 
vesicles, which are generally regarded as more characteristic of the 
disease, appear afterward in from a few hours to a day or more, spring 
from the macules or from the normal skin, and are accompanied by a 
sensation of heat. These typically perfect, isolated vesicles vary in 
size from that of a rape-seed to that of a coffee-bean. They appear in 
successive groups of from eight to a dozen or more, which gradually 
increase in size and attain maturity simultaneously in from three to 
seven days. 

The lesions, when fully developed, project well from the widely 
hyperseniic base from which they spring, are tense from complete dis- 
tention, and have no tendency to spontaneous rupture so firm is their 
roof- wall. Later their early limpid contents become lactescent or puri- 
fbrm in character. When abundant the vesicles may coalesce and form 

1 For complete bibliography, see Blaschko's article in Mracek's Handbuch, vol. i., 
p. 713. 



296 INFLAMMATIONS. 

irregular patches. Involution is accomplished by desiccation and the 
formation of a yellowish-brown crust, which falls in from seven to ten 
days after the first appearance of the vesicle. New groups appear during 
a period usually of from six to twelve days, at the end of which time 
vesicles may be seen in all stages of development and involution. The 
average duration of the disease is from ten days to three weeks. Ex- 
ceptionally, a succession of new lesions may prolong the disease for a 
month or more. 

Disappearance of the vesicles and crusts is followed often by pigmen- 
tation, which may persist for weeks or months. Scarring occurs in some 
cases, especially if the vesicles have been ruptured and exposed to pus- 
infection. The scars left by zoster are characteristic. Not only are 
they limited to the original seat of the disease, but they have also a 
peculiar indented look, as if made by a nail-set and hammer. They 
are angular in outline, and do not exhibit the dead-white color of many 
cicatrices. 

The pain or hyperesthesia of zoster varies greatly in intensity and 
in duration. It is usually mild, but may be very severe, especially in 
old people. It disappears commonly with, or soon after, the appear- 
ance of the eruption, but may persist for months or even for years. 

Zoster occurs chiefly in the upper part of the body, and, though 
limited to one side, this limitation is rarely observed exactly at the 
median vertical line, as a few lesions can usually be seen extending 
beyond this boundary. 

Atypical forms of zoster are seen occasionally. The vesicles may 
be typical and few in number, possibly limited to a single group, or 
they may be abortive and transitory. Papules or vesico-papules may 
be the sole lesions. The vesicles may become transformed into pus- 
tules or bullae, or be filled with blood from capillary hemorrhage, 
producing bluish or blackish lesions, known as Zoster H^mor- 
rhagictjs, or " black herpes." In severe cases there may be ulceration 
and gangrenous or deep-seated phlegmonous inflammation. Keloid- 
like scars occur rarely. 

Recurrent zoster 1 is rare, but a number of cases are reported in 
which an individual had two or more attacks either in the same or 
in different regions of the body. In many of the cases reported, how- 
ever, the recurrent lesions were not typical of true zoster. 

Zoster of simultaneous occurrence on two sides of the body may be 
symmetrical or asymmetrical of development. The disease in either 
form is exceedingly rare. In our experience the anomaly is generally 
the result of herpes either in a syphilitic subject or in one under the 
influence of arsenic. T. C. Fox 2 reports a symmetrical case in an 
infant of five months. 

The eruption may occur over the terminal filaments of nerves which 
have no communicating branches, unless, as suggested by Blaschko, 3 
there be an interlacing of fibres in the spinal cord. 

1 For a resume of the literature cf. "Becurrent Zoster," by Joseph Grindon, Jour. 
Cutan. Dis., 1895, xiii., p. 191. 

2 Brit, Jour. Derm., 1898, x., p. 252. 

3 Monatshefte, 1898, xxvii., p. 175. 



HERPES ZOSTER. 297 

Anomalous nervous symptoms are: persistence of neuralgia after 
involution of the cutaneous lesions; neuralgia of an intense and intol- 
erable severity at any period of the disease; painful anaesthesia of the 
skin ; paretic and paralytic phenomena with resulting muscular atrophy ; 
and, in zoster of the head, keratitis and iritis, complete destruction of 
the ocular globe, and falling of teeth and hair. 

According to the regions involved the following types of zoster are 
generally recognized : 

Zoster Capillitii depends upon involvement of the second branch 
of the fifth pair of nerves, and its lesions occupy the anterior and pos- 
terior portions of the scalp. 

Zoster Frontalis occurs in the area supplied by the supra-orbital 
nerve, which springs from the first branch of the trigeminus. Its 
lesions extend from the upper eyelid to the vertex, and spread in a 
fan-shaped figure over one-half of the brow, forehead, and scalp. 

Zoster Ophthalmicus may be a severe and dangerous manifesta- 
tion of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye, even resulting in pan- 
ophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. Typ- 
ical cases of zoster of this region may not, however, exhibit a single 
untoward symptom of the disease. 

Zoster Facialis depends upon involvement of the sensory nerve- 
fibres of the trigeminus distributed to the face, its lesions being dis- 
played over one cheek, the side of the nose, the half of the lip or of 
the chin. The facial and seventh nerves may chiefly be affected. Care 
must be taken in cases of this variety not to confound the disease upon 
the nose with acne or with painful tertiary syphilitic lesions, errors in 
diagnosis that have occurred. When the lower jaw is involved there 
may be severe toothache, dysphagia, and fall of the teeth, with great 
resulting deformity. 

Zoster Nuch^, seu Collaris, occupies the region extending for- 
ward from the cervical vertebrae to the clavicle, or upward toward the 
occipital region and the auricle. 

Zoster Brachialis occupies the region from the last cervical and 
first dorsal vertebrae over the supra-spinous scapular region and the 
contiguous portions of the upper arm. Rarely, even the skin of the 
fingers and that over the first and second ribs are involved. It is a 
common and usually a mild form of the disease, and is characterized 
by a peculiar isolation of the vesicular groups. It occurs also Avith 
lesions of exclusively brachial distribution. Thomson, of London, re- 
ports brachial zoster with involvement of the right internal cutaneous 
nerve in which two groups of vesicles appeared in the palm of the 
hand. 

Zoster Pectoralis is the most frequent form of the disease, from 
which the common name " shingles " originated. The eruption occurs 
below the first dorsal vertebra, covers the skin of the thorax as far as the 
lumbar vertebrae, and extends from the spinal column behind to the 
sternal region in front. Two, three, or more of the intercostal nerves 
in this region are commonly involved, and the neuralgia resulting has 






298 INFLAMMATIONS. 

frequently been mistaken for the pain of pleurisy. Children more 
often display this form than any other variety of zoster. 

Zoster Abdominalis. — The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. Zoster abdomi- 
nalis is usually much less pronounced in its features, and the exanthem 
is less abundant, than in the variety of the disease just described. 
When constipation exists defecation may be attended with consider- 
able pain. 

Zoster Femoralis covers the buttocks and sacrum, and extends 
along the thighs, sweeping from behind forward and from above down- 
ward as far as the popliteal space ; in some cases involving the leg and 
foot. The penis, the scrotum, the labia, the vestibulum vaginae, and 
the anus may then exhibit unilaterally arranged vesicles. As this is 
a relatively rare manifestation of the disease, the diagnostician will 
do well to recall the possibilities in every case of an exanthem lim- 
ited to one side of the perineum, supposed to be the seat of genital 
eczema. 

Etiology. — Herpes zoster occurs in both sexes, and in the young as 
well as in the old, though it is rarely seen in infants. It shows a ten- 
dency to increase in severity with the age of the patient, especially 
after middle-life. It is influenced by the seasons, as cold and damp 
weather serves to increase its frequency in those susceptible to it. 
Frequently there is a history of recent exposure of the involved region 
to a draught of cold air. A large list of other depressing agencies are 
named as effective in the production of zoster. Among them are 
certain poisons (carbon dioxide, belladonna, and atropine), pyaemia, car- 
cinoma, fever, measles, pulmonary inflammations (including phthisis), 
septicaemia, hemorrhages, traumatism, and malaria. 1 It also has fol- 
lowed vaccination, the passage of electrical currents, the extraction of 
teeth, an accidental prick by a thorn, the tapping of hydatids, and 
gunshot-wounds of the body. Curtin 2 reports ten cases in which zoster 
accompanied inflammation of serous membranes. Inasmuch as no 
one of these causes can be cited as certainly effective in all cases, it can 
merely be said that any influence sufficient to induce inflammation of a 
sensory nerve or its ganglion may be followed by the objective signs of 
the disease. In a few instances zoster has followed a prolonged course 
of arsenic. Occasionally zoster occurs in epidemics, or coexists with 
other epidemic disorders, such as influenza. The evidences of direct 
contagion in a few instances are very strong. These facts, and the 
rarity with which zoster recurs in the same individual, together 
with the adenopathy which is often present at the beginning of an 
attack, favor the growing belief that zoster is, in some instances at 
least, an infectious disease. 3 

Pathology. — In some cases there is unmistakable evidence of a de- 
scending interstitial neuritis, but the affection may be associated with 
irritative action in any portion of the nervous tract from central 

1 Of. Winfield, N. Y. Med. Jour., 1902, lxxvi., p. 191. 

2 Amer. Jour. Med. Sci., 1902, cxxiii., p. 264. 

3 Hay presents an excellent argument in favor of the infectiousness of zoster, and 
gives references to literature on the subject in Jour. Cutan. Dis., 1898, xvi. ? p. 1. 



HERPES ZOSTER. 299 

to peripheral limit. The researches of Barensprung, Rayer, Wagner, 
Charcot, Kaposi,, and others have demonstrated with sufficient clearness 
that in zoster there are always, at some point in the corresponding 
nervous tract (cerebral or spinal centres, ganglia, or the nerves them- 
selves), pathological changes. In the majority of cases in which a 
pathological lesion is demonstrated there is found an interstitial neuritis 
of the posterior ganglion or of the posterior spinal root, but neuritis 
and perineuritis of the peripheral nerves, without change in the more 
centrally situated parts of the nervous system, are reported by com- 
petent observers. In a number of cases multiple neuromata have been 
discovered along the affected nerve, the spinal cord and ganglia remain- 
ing normal. In other instances the irritation of the nerve-tract has 
been due to hemorrhage, degeneration, or pressure from tumors, etc. 

Head and Campbell 1 have been able to make post-mortem exami- 
nations in twenty-one cases. They found inflammatory and secondary 
degenerative changes not only in the ganglia of the posterior roots, but 
also in the posterior roots themselves, in the root-fibres of the poste- 
rior columns, and in the peripheral nerves. Reflex irritation seems to 
have been an effective cause in a few cases. 

According to Biesiadecki and Haight, the cutaneous lesions originate 
in the deeper portions of the rete, precisely as in other vesicular dis- 
eases. The exudate from the hyperaemic corium, especially its papil- 
lary layer, presses upward into the rete, the epithelia of which are 
thus separated and vertically elongated, the lacunae between them 
being distended with serum and a few round cells. Often the vesicles 
form about the hair-sacs. As the exudation increases the rete-cells 
are progressively separated, and finally are discovered free in the ex- 
uded fluid, though some, in changed form but still united to each other, 
may be found in the upper part of the vesicle. Except at the margin, 
the mucous and horny layers are separated by the exudation. At first 
many-chambered with delicate easily ruptured partitions, the vesicle 
represents finally a single chamber filled with serum containing rete- 
cells and a few pus-cells, the latter increasing in number as the vesicle 
changes its type. Its base at first rests upon the lower portion of the 
mucous layer ; later, upon the corium itself, in which all signs of pa- 
pillae are absent. In the vicinity of the vesicle the papillae and corium 
are infiltrated and the vessels are dilated, but these inflammatory 
changes do not extend far into the corium. The deep location of the 
vesicle, resting as it does upon the papillary layer, accounts for occa- 
sional destruction of the papillae and consequent scarring. 

The vesicle of zoster (and to a less degree that of variola and of 
varicella) is peculiar in that it contains in the deeper portion and along 
the walls epithelial cells which have undergone transformation into 
round or ovoid globular bodies, usually larger than the normal cells, 
which have apparently a limiting membrane or double-contoured wall, 
and contain from two to a dozen or more rounded bodies. These trans- 
formed epithelial cells have been described as protozoa, but their true 
nature has been demonstrated by Unna, Gilchrist, 1 and others. Other 

1 Brain, 1903, xxiii., p. 362 (monograph, well illustrated). 

2 Johns Hopkins Hosp. Rep., 1896, yii., p. 138. 



300 INFLAMMATIONS. 

varied and extraordinary figures are seen. Among them are rings with 
fragmentary edges and swollen centres (the edge representing a homo- 
genized and fibrinously degenerated protoplasm ; the centre a homo- 
genized nucleus). Elsewhere are thin and expanded shells filled with 
epithelial nuclei. Irregularly " ballooning " balls, baskets, tubes, hang- 
ing cords, and other odd forms take the place of the trabecule found in 
other vesicles. Unna names this peculiar change in the epithelial cells 
a " ballooning degeneration/ 7 to distinguish it from the • reticulating 
forms. Kopytowski 1 states that these forms are due to an cedematous 
degeneration (views based on an examination -of sixteen cases). Pol- 
litzer 2 reports an unusual case in which the vesicles were limited to 
the rete Malpighii of the hair-follicles. 

Diagnosis. — The vesicles of herpes zoster are not rarely confounded 
with those of eczema ; but the distinction between the two is always 
readily established. In eczema there is itching but no neuralgia ; the 
vesicles tend to rupture spontaneously and never persist as they do in 
zoster ; eczematous lesions are also smaller, more acuminate, and rarely 
distinctly limited to the lateral half of the body. Herpes simplex is 
frequently recurrent, herpes zoster almost never; herpes simplex is 
exceedingly liable to spread around the mucous outlets of the body, 
and on either side of the latter, while zoster reaches such regions only 
after extension from other parts, and is then almost invariably mono- 
lateral. Its lesions are, moreover, never grouped in the concentric 
circles of herpes iris. 

Treatment. — The purpose of local treatment of herpes zoster is to 
protect the vesicles from rupture and infection, and to relieve pain. 
These ends are best accomplished by thickly dusting the lesions with 
an anodyne powder, such as Anderson's powder, containing morphine 
sulphate, 2 grains (0.133) to the ounce (30.) ; lycopodium with powdered 
opium, orthoform and boric acid, or zinc stearate with acetanilid, etc. 
The vesicles may be punctured with an aseptic needle and the contents 
evacuated, but rupture of the lesions should not be permitted. Over 
the entire affected surface should be gently laid a sheet of soft lint or 
of antiseptic cotton, its meshes being also filled with the powder, and a 
bandage, when practicable, smoothly bound over the whole. In the 
milder cases nothing more than this treatment is needed from first to last. 
The glycogelatins furnish a convenient and effective dressing if the con- 
tents of the vesicles be first evacuated and the surface rendered as nearly 
aseptic as possible. Small areas of newly formed vesicles may be cov- 
ered with flexile collodion. In cases in which the lesions have ruptured 
and their bases have undergone erosive or ulcerative changes, oleated 
lime-water with zinc oxide, belladonna, and opium or morphine should 
be applied, and be covered with Lister protective. Carbolated and 
anodyne ointments may also be used, especially toward the conclusion 
of the case. Bleuler 3 states that applications of 1 part of cocaine in 
50 parts each of lanolin and vaselin not only relieve the pain, but also 
shorten the duration of the disease. 

1 Archiv, 1900, liv., p. 17. 

2 Jour. Cutan. Dis., 1903, xxi., p. 73. 

3 Neurologisches Centralblatt, 1899, xviii., p. 1010. 



HERPES ZOSTER. 301 

Lotions of carbolic acid and glycerin (1 part to 6), or lead-water 
and laudanum, or the " lead-and-opium wash" may be employed. 
Van Harlingen recommends ^ ounce (15.) each of precipitated zinc 
carbonate, powdered zinc oxide, powdered starch, and glycerin, shaken 
up in \ pint (240.) of water. 

Duhring speaks well of collodion with morphine, in the strength of 
10 grains (0.66) to the ounce (30.). Kaposi warns against the use 
of diachylon ointment. Generally, it may be said that ointments 
should be the last resort, but those containing from 10 to 20 grains 
(0.66-1.33) of the aqueous extract of opium or of belladonna to the 
ounce (30.), or a 5 per cent, cocaine salve, will at times give relief from 
pain. The oleate of cocaine and menthol have been used locally with 
great advantage in meeting the same indication. Alcohol ; or resorcin 
2 parts, alcohol 100 parts ; or 1 per cent, alcoholic solutions of menthol 
or of thymol, may be useful when other measures fail, and it is claimed 
by some that these remedies will abort the disease if used early. A 
continuous galvanic current of between two and three milliamperes 
may be applied over the root of the nerve two or three times daily 
for ten minutes at a sitting. Blistering or dry-cupping, or in sthenic 
cases wet-cupping, may be employed instead of electricity. 

No remedy for internal use is known to have the power of abort- 
ing or of shortening an attack. Quinine is certainly indicated and does 
no harm, but quinine and strychnine in full doses have alike proved 
inefficacious. Other remedies employed are zinc phosphide in ^ grain 
(0.022) doses, repeated every three hours, and, if indicated, in com- 
bination with ^ (0.011) grain of the extract of nux vomica; arsenic 
(Kaposi) ; and the tonics in general. Anodynes, by mouth or by hypo- 
dermatic injection, are often indispensable. Inasmuch as many patients 
consider the attack a trivial matter, it is of some consequence that they 
be warned of the possibilities of the future, and that they be confined 
to an apartment of equable temperature in which they are not exposed 
to atmospheric changes. This measure is of special importance in the 
zosters of the face. A skilled oculist should be consulted in cases in- 
volving the eye. 

Prognosis. — Zoster usually runs a benign and self-limited course. 
The prognosis in exceptional cases may be in the highest degree grave. 
Many severe cases have occurred in Avhicb patients, after years of 
intense suffering, have resumed the occupations of life, physical wrecks 
of their former selves, their faces indented with scars, and the vision 
of one eye impaired or ruined. Rarely the termination is fatal. 



302 INFLAMMATIONS. 



DERMATITIS HERPETIFORMIS. 1 

(Herpes Cikcinattjs Bullosus [E. Wilson], Herpes Gestationis 
[Milton, Bulkley, and others], Pemphigus [Klein], Pemphigus 
Circinatus [Rayer], Herpes Phlyctjenoides [Gibert], Herpes 
Iris [Jarisch], Fatal Pemphigus-like Dermatitis [Mayer], 
Peculiar Skin-eruption recurring during Pregnancy 
Oswald], Bullous Eruption of a Peculiar Character 
[Leigh], Hydroa [Jones and Bulkley], Duhring' s Disease, 
Hydroa Herpetiformis. Fr., Maladie de Duhring, Pem- 
phigus compose [Devergie], Pemphigus aigu prurigineux 
[Chausit], Pemphigus prurigineux [Hardy].) 

Dermatitis herpetiformis is a cutaneous affection commonly sub- 
acute or chronic in career, characterized by the production upon the 
skin, of vesicles, pustules, blebs, or papules, often in multiform combi- 
nation, usually grouped, often accompanied by pigmentation, producing 
excessive pruritic and burning sensations, frequently recurrent, and 
rebellious to treatment. 

Dermatitis herpetiformis is a malady which, in one form or another 
and under different titles has long been recognized and described. 
The credit, however, of clearly establishing its identity, and of recog- 
nizing one process as differently described in the several observations 
of others, is due to Duhring, of Philadelphia. 

Symptoms. — Constitutional symptoms are usually slight or wanting, 
but the first appearance of the disease and the succeeding attacks or 
exacerbations frequently are announced by malaise, sensations of chilli- 
ness, decided rigors, or alternations of cold and hot sensations, with 
systemic disturbances. The skin usually is the seat of pruritic or 
of burning sensations, followed in the course of from twelve hours to 
two days by the appearance of the exanthem, which may be macular, 
papular, tubercular, vesicular, pustular, or bullous in type, very rarely 
purpuric, or represent multiform combinations of these lesions recurring 
in every variation. The lesions may be cutaneous, muco-cutaneous, or 
mucous in situation, and often are disposed symmetrically. 

The macular form of eruption appears in small-coin- to palm-sized 
patches, irregularly rounded, coalescing, well or ill defined as to out- 
line, and slightly raised, suggesting the lesions of erythema multiforme 
or urticaria. Often there are formed infiltrated areas of a vividly red 
hue on which other lesions are developed. Imperfectly defined maculo- 
papules, papules, and papulo-tuberculous lesions, varying in shape, 
size, and firmness, may also spring from or be intermingled with the 
reddish maculations described above. 

1 " Dermatitis Herpetiformis ; its Eelation to So-called Impetigo Herpetiformis." 
Amer. Jour. Med. Sci., October, 1884. " Dermatitis Herpetiformis ; Case of, Caused by 
Nervous Shock," etc. Ibid., January, 1885. "Case of Dermatitis Herpetiformis, Illus- 
trating the Pustular Variety of the Disease." Jour. Cutan. Dis., i., No. 8. " Case of 
Dermatitis Herpetiformis with Peculiar Gelatinous Lesions." Med. News, March 7, 
1885. " Notes of a Case of Dermatitis Herpetiformis," etc. N. Y. Med. Jour., Novem- 
ber, 1884. " A Case of Dermatitis Herpetiformis (Bullosa)." Ibid., July, 1884. Cf. 
Duhring, p. 436. For bibliography, see Brock, La Pratique Dermatologique, vol. i., 
p. 651. 



PLATE III. 




Dermatitis Herpetiformis. 



DERMATITIS HERPETIFORMIS. 303 

In typical development, however, the disease presents vesicular 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pinhead- to bean-sized, and 
tensely distended. They may be pale yellow or darker in color and 
with or without areola?. When bulla? form they may be sparse or be 
plentiful, and be bean- to egg-sized, with cloudy, lactescent, hemor- 
rhagic, or purulent contents. Pustules when present are single or are 
clustered, pinhead- to bean-sized lesions, flat, each surrounded by a 
livid areola. 1 When evolution is complete, segments of rings, or dis- 
tinct rings, of new minute or large pustules surround those first formed, 
and in less than a week these rupture and become covered with a 
crust, which is flat, adherent, and yellowish, greenish, brownish, or 
blackish in color. When there is coalescence a large coin-sized pustule 
and crust may result, and even extensive patches of these coalesced 
lesions may form. The lesions may number from a score or fewer to 
hundreds. 

The imprint of the cutaneous symptoms is multiformity, recurrence, 
and variation in type from one efflorescence to another. Vesicles, pus- 
tules, and bullae without order or regularity of evolution or of recur- 
rence appear at one and the same time, in rapid or in slow succession, 
and, without fixed intervals of appearance, for months at a time. 
Generally, however, a prevalence of one special type of lesions may 
be noted during a single period of outbreak or of recurrence. This 
prevalence is in the direction generally of lesions of an herpetic type, 
viz., the vesicular and the bullous in groups, though less frequently 
one of the other types may predominate, and rarely vesicles may be 
absent. The surface may be invaded partially or generally ; often only 
the trunk and extremities are involved. Occasionally vesicles and 
blebs are filled with blood. 

As a result of the conditions described above a peripheral new for- 
mation of lesions tends to produce marginate patches in which grouping 
occurs, the groups, however, being interspersed with diffusely dissem- 
inated lesions of various types. The irregular, angular, or stellate 
forms of the lesions containing fluid are highly suggestive. Pigmenta- 
tion and infiltration of the skin are commonly noticed. The subjective 
sensations of burning increase and diminish as cutaneous lesions are 
multiplying or are disappearing. The pruritus is in some cases more 
severe than in eczema, and the traumatisms of scratching add greatly 
to the multiform features of the disease. 

The disease lasts for months and even for years. Duhring reports 
cases lasting from five to fifteen years, with periods of relative or of 
entire immunity. In one of Duhring's cases there were thumb-nail- 
sized, raised but flat, golden-yellow-colored lesions, of firm consistency, 
containing a similarly colored, thick, consistent, gelatinous pulp ; these 
features have been noted in other instances. 

When the oral cavity is invaded there appear upon the sodden and 
macerated mucous surface pustules and bulla?, which rupture, leaving 
raw and unhealthy -looking erosions, even sloughing patches of mucous 
membrane. Crusts form about the nares and the lips, and the stench 

1 Cf. Wende and Pease, " A Case of Dermatitis Herpetiformis, Illustrating an Un- 
usual Pustular Variety of the Disease," Jour. Cutan. Dis., 1901, xix., p. 171. 



304 INFLAMMATIONS. 

from the patient is intolerable. In the same way the vulva, the anus, 
and the prepuce may be surrounded by vesicular and bullous lesions, 
which form also on the mucous surfaces adjacent and pursue a course 
similar to that recognized in the mouth. 

In grave cases, as the skin-symptoms exhibit a marked aggravation 
the systemic condition changes for the worse. Crusting, lymphangitis, 
adenopathy, lichenification may be the results of scratching and secon- 
dary infection of the skin. After a low fever alternating with chills 
and accompanied by progressive cachexia and emaciation, an inter- 
mittent diarrhoea or a pneumonia may close the scene. The repulsive 
appearance of the patient at the last, in severe cases, is as formidable 
as in fatal cases of confluent variola or of severe pityriasis rubra. 

Herpes Gestationis (Pemphigus Hystericus). — The special 
form of dermatitis herpetiformis occurring in pregnancy does not 
differ in its general features from the types of the disease seen in non- 
pregnant women and in men ; but there can be no question that the 
pregnant condition in many cases bears close relation to the eruptive 
phenomena. Vesicles, blebs, papules, macules have been observed 
repeatedly in successive pregnancies of the same woman and in that 
subject at no other time. The lesions in these cases are exceedingly 
pruritic ; often are developed symmetrically over large areas of the 
surface ; and may be relieved completely before the termination of 
gestation, or only at that period. In a few instances both death of 
the foetus and persistence after delivery have been reported. The 
child may be born into the world in a condition of sound health, 
though the nervous system of the mother commonly is affected pro- 
foundly during and often for some time prior to the occurrence of 
pregnancy. 

Hydroa Bulleux is a rare pruriginous form of the same disorder 
which may be accompanied by a febrile movement. The eruption 
develops with vesicles of medium size, which later increase and mul- 
tiply, become slightly umbilicated, desiccate, and are covered with 
crusts of variable size and color according to whether there has or has 
not been secondary infection as a result of the scratching. The erup- 
tive elements appear in crops accomplishing cycles of evolution and 
may be generalized extensively, even invading the palms and soles. 

Complications of all forms of dermatitis herpetiformis are : the 
involvement of the nails, which may be shed ; the occurrence of scars 
only after secondary infection of lesions and ulceration ; vegetations, 
as in pemphigus vegetans ; marked cachexia ; and, lastly, serious 
disturbance of the nervous system in consequence of long-continued 
anxiety as to the health and distress produced by the eruptive symptoms. 

Etiology. — The disease occurs in both sexes and at all ages, but 
somewhat more commonly after adult years have been attained : often 
in individuals of neurasthenic type or in those in whom the nervous 
system has been subjected to unusual strain. Mental crises, nervous 
shock, fright, anger, menstrual irregularities, pregnancy, the puerperal 



DERMATITIS HERPETIFORMIS. 305 

state, septicaemia, physical fatigue, exposure to cold, and defective renal 
excretion have all been cited as causes of the malady. It is possible 
the irritation of the nervous system may be due in every case to a 
toxaemia, but by many the disease is considered purely a neurosis. 

Pathology. — Histological examination shows an acute inflamma- 
tion in the upper part of the corium, chiefly in the papillary layer. 
There are dilatation of the vessels, marked oedema with infiltration of 
the lymph-spaces, and some plasma-cells. The vesicles are formed 
rapidly as a rule between the basal layer of the rete and the papillary 
body. Larger vesicles are formed frequently by the confluence of 
smaller ones, and they all are filled more or less with a fine or coarse 
network of fibrin containing polymorphonuclear with some mono- 
nuclear and eosinophile cells, red blood- and epithelial cells, and also 
coagulated albumin. The eosinophiles are found in the vesicles and in 
the blood-vessels and lymph-spaces of the corium, and frequently 
between the epithelial cells. The deeper portion of the corium is un- 
changed for the most part. Eosinophilia is present as a rule, but its 
exact significance is not established, as it is found in other conditions. 
Lerrede l believes that eosinophilia when combined with excretion of 
eosinophiles through the skin is peculiar to dermatitis herpetiformis 
and allied conditions. 2 

The Diagnosis in classical cases is made readily ; in others the dis- 
tinction between dermatitis herpetiformis, impetigo herpetiformis, and 
certain forms of pemphigus is exceedingly difficult. It is possible that 
between the three there may be transitional forms scarcely to be assigned 
to the one category or the other. The same is true of certain excep- 
tional varieties of erythema multiforme. 

The diagnostic features of the disease are : chronicity, with or with- 
out remissions or intermissions ; multiformity of the lesions, among 
which those of herpetic type usually predominate ; the tendency of the 
lesions to appear in groups or patches ; the very marked capriciousness 
and variableness of the recurrences and exacerbations in their times of 
appearing, and in the nature, extent, and severity of the lesions; itching, 
often intense ; and more or less pigmentation. 

Treatment. — Internal treatment has been directed to meet the indi- 
cations presented. Of great importance are hygienic measures with a 
view to maintaining the patient's general health. All excesses, excite- 
ment, and everything tending to interfere with the equilibrium of the 
nervous system should be avoided. A nutritious but simple diet, regu- 
lar habits of living, with sufficient outdoor life and exercise, are all of 
great value. Medication is directed chiefly toward improving the tone 
of the nervous system, for which purposes strychnine, quinine, iron, 
small doses of arsenic, and phosphorus may be used. Preparations of 
malt and cod-liver oil are often indicated. Mild laxatives, and the free 
drinking of water between meals and before meals, are of value in 
aiding elimination. For the same purpose small doses of mercurous 

1 Annales, April, 1899, s. iii., x., p. 836. 

2 For a full discussion of the relation of this disease to allied vesicular and bullous 
dermatoses, cf. articles by Jamieson, Brit. Jour. Derm., 1898, x., pp. 73 and 118 ; Brocq, 
Annales, 1898, pp. 849 and 945 ; and Lerrede, Monatshfte, 1898, xxvii., p. 381. 

20 






306 INFLAMMATIONS. 

iodide may be continued for weeks at a time. Stelwagon has found 
general galvanization of value in one or two patients. In exceptional 
cases arsenic in full doses acts almost as a specific ; it is of most value 
in vesicular and bullous eruptions. It should be remembered that 
when arsenic is not suited to a given case large doses of the drug may 
do much harm. Crocker prefers salicin in 15 grain (1.) doses. 

Other existing disturbances of the general economy due to rheu- 
matic tendencies, kidney-disease, indigestion, constipation, or other cause 
should be recognized and properly be treated. 

Locally treatment is directed to keeping the surface clean and aseptic, 
and to making the patient comfortable. Duhring recommends stimu- 
lating applications when they are well tolerated, but in many cases 
soothing and sedative preparations are necessary. Among the stimu- 
lating applications which have proved of value may be mentioned 
lotions and oils containing tar, carbolic acid (1 to 20 per cent.), ichthyol 
(2 to 10 per cent.), and thymol (1 to 5 grains (0.06-0.33 to 30.) to the 
ounce). Stelwagon highly recommends liquor carbonis detergens in 
strength varying from 1 part to 10 parts of water up to the pure solu- 
tion. Duhring found weak sulphur ointments (2 grains (0.13) to 
the ounce (30.) ) of value in cases in which there were vesicular, 
pustular, and bullous lesions. This ointment should be rubbed in vig- 
orously, but should be tried on a small surface at a time for fear of 
inducing irritation. 

In most cases a soothing treatment is demanded by means of alka- 
line, bran-, or other demulcent baths, followed by some of the dusting- 
powders or the lotions advised for use in the acute stages of eczema. 
Ointments are not indicated, as a rule, but in a few cases diachylon oint- 
ment (Hebra), Lassar paste, zinc, mercurial, and other pastes and oint- 
ments have been used to advantage. For relief from itching camphor 
and chloral (1 to 5 per cent.) in oils or ointments may be employed. 
Many patients are treated with very great comfort to the end in the 
continuous warm water-bath. 

The Prognosis is always doubtful, and may be at times grave. 
Temporary recovery from repeated outbreaks is common. Persistence 
for years Avith periods of aggravation and decline are the rule. Bril- 
liant recoveries, however, occur under skilful treatment. 



POMPHOLYX. 

(Gr. TTo/Kpo/M^ a bubble.) 

(Cheiro-pompholyx, Dysidrosis. Fr., Dysidose.) 

Pompholyx is a disorder affecting the skin of the hands and feet, 
occasionally also contiguous parts, where variously sized vesicular and 
vesico-bullous lesions develop. 

This disorder has been the theme of no little discussion. It was 
described first by Tilbury Fox in 1875, Hutchinson ' reporting on the 

1 Amer. Jour. Derm., 1875, i., p. 1 ; Illustrations of Clinical Surgery, vol. i., PI. x. ; 
for bibliography, see Santi, Monatshefte, 1892, xv., p. 93. 



POMPHOLYX. 307 

same case. Kaposi asserts that the symptoms are those simply of 
acute eczema. 

Symptoms. — The disease affects simultaneously and, as a rule, 
symmetrically the hands and the feet ; if either organs are spared, it is 
commonly the feet. One side may be involved more extensively than 
the other. The eruption is preceded or is accompanied by a burning 
or a tingling pain, rarely with severe itching, and is characterized 
by the appearance on the dorsum, or the sides of the fingers, or over 
the palms and soles, or over the whole hand or foot, of deeply set, 
single or numerous, grouped or confluent pin-head- to bean-sized 
vesicles, or of vesico-bullse. According to Fox, in the earliest stages 
of the vesicles annular collections of fluid may be seen about the sweat- 
pores. The appearance of well-developed lesions is compared with that 
of boiled sago-grains imbedded within the skin. When the bullae attain 
extreme development the distended lesions, as large as pigeon's eggs, 
project from the skin, these lesions being irregularly outlined and con- 
taining a neutral or an alkaline fluid, translucent or turbid, and seated 
on an cedematous, often exquisitely painful and sensitive skin. The 
bullae are said not to rupture spontaneously, but to undergo absorption 
in a fortnight or more, with exfoliation of the loosened epidermis ; but 
there are well-marked exceptions to the rule. Beneath the purposely 
ruptured bullae is a new-formed and reddened or exfoliated and sodden 
(which under favorable circumstances becomes later a sound) epidermis. 
There may be coincident malaise, thermal changes, marked mental de- 
spondency, or hebetude. The hyperidrosis mentioned by some authors 
may or may not be a prominent feature in the case of affected patients 
before and during the occurrence of the disease. There may be recur- 
rent attacks in consecutive seasons, and also recrudescence of the dis- 
ease in the affected. Mild types of the disease occur which it is diffi- 
cult to distinguish from pemphigus benignus. 

Etiology. — The disease is somewhat rare, occurs rather more often 
in women than in men, though both sexes are attacked. The ages 
extend from childhood to middle life ; one well-marked case occurred 
in a man of sixty. The sufferers, with but few exceptions, are in poor 
health, are broken down from nervous overstrain, and are neurasthenic 
rather than cachectic. 

The disorder is in certain subjects due to strictly inherited tendencies. 
We have had under observation three typical cases in the person of a 
mother and two children, one of the latter a girl, all of whom had 
suffered since birth from successive crops of vesico-bullous lesions with 
hyperidrosis of the hands and feet. The heart of each was in an irrita- 
ble state, the pulse-rate of the mother having been repeatedly registered 
at 122 to the minute. All three patients complained of gastric crises. 

In France a number of disorders accompanied by coldness and 
sweating of the hands and feet, and characterized by lesions limited to 
these organs, are cited as instances of dysidrosis. Thus, a passive ery- 
thema and areas of congestion of the skin of the organs named, dis- 
playing non-bullous lesions, are commonly set down in Paris as illus- 
trations of dysidrosis. It is usual in America to limit the titles 
dysidrosis and pompholyx to the affection here described with marked 
preponderance of vesico-bullous lesions as hand and foot symptoms. 






308 INFLAMMATIONS. 

In all cases the heart should be examined and the condition of the 
circulation carefully determined. Organic and functional cardiac dis- 
ease is responsible for many cases. 

Pathology. — The differences among observers respecting the char- 
acter of the disease depend upon whether the view is taken with Fox, 
Crocker, and others, that the vesicles lie directly connected with or in 
the line of the sweat-duct ; or whether, with Hutchinson, Robinson, 
and others, no connection with the coil-glands is recognized, the vesi- 
cles lying in the superior portions of the rete over the papillae, and not 
over the rete-pegs which pass below to meet the ducts of the coil- 
glands. Crocker, however, found lesions in both situations. Unna 
believes that a micro-organism resembling the tubercle-bacillus is 
responsible for the disease. 

Diagnosis. — Pompholyx is to be differentiated from eczema. The 
tendency of the vesicles to persist, and after intentional rupture to fail 
to furnish a serous exudate, is strikingly different from the course of 
eczema. Again, there is seldom, if ever, in well-marked pompholyx a 
tendency to change in type from a serous to a pustular exudation. 
Lastly, eczema of the palms and the soles is almost invariably of ery- 
thematous type. It differs from pemphigus in the absence of cyclical 
phenomena, in its special localization, and in its frequent vesicular 
origin. 

Treatment. — The internal treatment of these cases is of importance. 
Patients require the best climatic and hygienic environment and mental 
distraction. In the way of medicaments, quinine, nux vomica, iron, 
the mineral acids, ergot, cod-liver oil, matzool, and kumyss may be 
needed. The local treatment is by employment of diluted black wash ; 
oleated lime-water Avith zinc oxide or bismuth subnitrate, or Lassar 
paste covered with boric or salicylated powder ; or by the application 
of strips of muslin spread with lead or with zinc salves. Crocker 
recommends the zinc or lead oleate. In other cases solutions of silver 
nitrate (grains v to ^j [0.33-30.] or of ichthyol 50 per cent, with 
water are efficacious. 



PSORIASIS. 1 

(Gr. ipopa, the itch.) 

(Lepea, Alphos, Psora. Ger., Schuppenflechte). 

Psoriasis is a chronic, occasionally acute, inflammatory disease, char- 
acterized by reddish-brown flat papules or sharply circumscribed plaques 
or areas of varying size covered with silvery- white imbricated scales. 
The disease is a common one, and usually presents such a characteristic 
picture that its recognition is not difficult. 

Symptoms. — The papules and plaques of psoriasis always are 
defined sharply from the surrounding skin, somewhat infiltrated, 
slightly elevated, and covered more or less completely with silvery- 
white or mother-of-pearl colored scales which are arranged in thin 

1 For complete bibliography, see Grosz, Mracek's Handbuch, Bd. ii., pp. 126-168. 



PSORIASIS. 309 

layers like mica. On removal of the scales there is exposed in recent 
lesions a bright-red surface ; in older lesions the color is of a duller 
hue. If the deepest scale, which often is thin, translucent, and closely 
adherent, is pulled or scraped off, there can be seen several minute 
bleeding points which correspond to the apices of papillae beneath. 
The lesions vary greatly in number, size, shape, and distribution, but 
the type, that of the dry papule or plaque covered with scales, remains 
always the same, so that in uncomplicated cases psoriasis is distinctly a 
dry disease without vesicles, pustules, or other moist lesions. 

The primary lesion of psoriasis is a pin-point- or pin-head-sized flat, 
round or oval, sharply defined, slightly elevated red papule, which 
always at the earliest moment of observation is covered either entirely, 
or all but a narrow rim at the border, with delicate silvery -white or 
mica-like scales. The bleeding points produced by forcibly removing 
the scales may be so minute that they are only visible with the aid 
of a lens. As the lesion grows peripherally, it may become somewhat 
more infiltrated, slightly more elevated, and covered with more 
abundant imbricated scales, but otherwise it retains its original char- 
acteristics. Larger plaques and areas all are formed either by the 
gradual increase in size of the original papules, or by the coalescence 
of a number of papules or smaller plaques. The papules and small 
plaques formed by the peripheral growth of single papules are usually 
round or oval, but areas formed by the coalescence of smaller plaques 
are irregular in outline. In the borders of such patches traces of the 
original lesions can usually be detected. As a matter of convenience, 
descriptive terms have been applied to the lesions of psoriasis to denote 
their size and arrangement. 

When the disease appears in the form of small scale-covered points, 
it is called jjsoriasis punctata. Should the disease progress to fuller 
development, patches of larger size form, always w T ith a definite con- 
tour, very slightly elevated above the general level of the integu- 
ment, and covered with whitish, mother-of-pearl colored scales in 
abundance. When the lesions are about the size of drops of water, the 
disease is termed psoriasis guttata. In more advanced conditions of 
the disease other names are employed. Thus, psoriasis nummularis 
or discoidea is characterized by small-coin-sized patches ; psoriasis cir- 
cinata, or orbicularis, by patches in which the disease is exhibited 
actively at the periphery of a circle, the centre of which is free from 
disease, a condition due usually to the involution of the centre of an 
area as it extends peripherally ; psoriasis gyrata and Jigurata, by coal- 
escence and extension of several patches, forming thus fantastic figures ; 
and psoriasis diffusa, by much more extended and uniform involvement 
of the skin in large areas. In psoriasis foUicularis the coil-glands 
and hair-follicles are invaded chiefly. 

Areas of long persistence in which the skin is infiltrated deeply, often 
fissured, and covered with heavy scales, are designated frequently as 
psoriasis inveterata. In a given case the lesions may be of fairly uni- 
form size, but more commonly, if at all numerous, they exhibit differ- 
ent stages of development and therefore vary in size. They may be 
arrested at any stage of growth and persist for months or years as 



310 INFLAMMATIONS. 

guttate, nummular, or larger plaques, or by continued extension and 
coalescence form areas covering an entire region of the body. Though 
cases are reported in which the surface of the entire body is covered, 
it is rare that areas of normal skin cannot be detected. 

In number and distribution of its lesions, and in its course, psori- 
asis varies greatly. The disease commonly begins with one or two 
small papules which increase slowly in size. In ordinary cases new 
lesions appear during the course of weeks, months, or years, until there 
are from ten to one hundred or more patches of varying size scattered 
over the body. It is not unusual, however, for the disease to remain 
for years limited to two or three coin-sized areas, situated commonly 
over the elbows and knees. Occasionally a single patch may per- 
sist indefinitely without the appearance of others. In other instances, 
but chiefly in recurrences of the disease, a large number of punctate 
papules may appear within a few days. In the same individual, the 
number, size, and distribution of the patches vary from time to time. 
With many patients the psoriatic areas partially or wholly disappear 
in summer, only to return in cold weather. In a smaller number 
of cases the disease is worse in summer, and better, or entirely absent 
in winter. Without the influence of climate or of any other known 
cause, the disease may disappear partially or wholly for months or years 
and then return. In recurrences of the disease the lesions do not neces- 
sarily correspond in number, size, or distribution with those of earlier 
attacks. In acute febrile and other intercurrent diseases patches of 
psoriasis may fade or disappear temporarily. 

Involution of a patch of psoriasis begins in the centre, and is recog- 
nized by a diminution in the hyperemia and of the scaling. The process 
progresses slowly until no trace of the disorder is left. Temporary 
pigmentation may remain for weeks, on the lower extremities for 
months, after the scaling and infiltration have disappeared completely. 
Should the areas spread peripherally while healing in the centre, cir- 
cular and oval bands are formed. By the union of a number of such 
bands are produced circinate and gyrate figures or festoons which may 
occupy the entire surface of the back or other region of the body. 

In distribution, psoriasis is, as a rule, symmetrical, but exceptions 
to the rule occur. The sites of preference of the disease are the ex- 
tensor surfaces of the extremities, especially about the elbow and the 
knee, in which situation it is decidedly most common. After these loca- 
tions should be named, in order, the scalp, the region of the sacrum (on 
which often the largest patch upon the body can be discovered), the 
upper surface of the chest, the face, the belly, and the genitals, more 
rarely the hands and the feet. 

Upon the scalp, plaques of well-defined contour, covered with thick 
whitish scales, may mat the hairs, but alopecia rarely results. The 
dry condition of these scales contrasts with the greasiness of the 
crusts formed in seborrhcea of the scalp. Often a fillet or band of 
diseased tissue, one or more inches in width, projects beyond the 
border-line of the scalp and forehead. When the vertex is bald from 
physiological loss of hair the patch of psoriasis usually lingers near the 
fringe of the hairs left at the sides of the head, projecting thence to the 




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PSOBIASIS. 311 

regions of baldness. On the face, as well as over the genitals, the 
lesions are usually both indistinct and small-sized, being displayed, as 
regards the former locality, over the cheeks, chin, and nose, avoiding 
the parts near the mucous orifices. On the scrotum psoriasis frequently 
is complicated by fissures, moisture, and other evidences of acute 
inflammation. 

The hands, feet, fingers, and toes are not often involved, and the palms 
and soles only so rarely invaded as to throw doubt upon a diagnosis based 
upon the existence of the disease solely in these regions. We have had 
two cases in which the disease was limited to the palm for considerable 
periods of time, but later appeared in characteristic forms on other parts 
of the body. Other writers report similar instances. In severe cases 
the nails are attacked secondarily, being thickened, eroded in points, 
irregularly laminated, rigid, and becoming brittle and yellowish-white 
or dirty-whitish in color. On the palms and soles the lesions may 
show, instead of scaling, sharply circumscribed areas in which the 
horny layer is much thickened. Through cracking and partial destruc- 
tion of these horny masses the patches may assume a worm-eaten 
appearance. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called " psoriasis linguae " are those of " leukoplakia buccalis," 
or " smokers' patches," of syphilitic disease of the mouth, or flat epi- 
theliomata. 

Schutz 1 reports two cases and refers to others, in which psoriasis 
was associated with mucous membrane lesions. These lesions, how- 
ever, occur with other cutaneous and systemic disorders, and their rela- 
tion to psoriasis is not demonstrable. 

In a patient subject to psoriasis a local irritation, such as a pin- 
scratch, a mustard plaster, may cause new lesions to appear at the site 
of irritation. Crocker 2 describes a form of psoriasis punctata in which 
the lesions, though numerous, are limited to the sweat-ducts, and an- 
other form of punctate psoriasis in which the papules are situated about 
the hair-follicles. 

The amount of scaling varies greatly in different persons and in the 
same individual ; ordinarily the scales are abundant and thickly heaped 
up over even small areas ; sometimes they are sparse over large areas. 
Free perspiration, friction by the clothing, or frequent bathing may 
prevent the accumulation of scales on areas where they would other- 
wise be abundant. Where the epidermis is thin the scaling is less ; 
therefore, over flexor surfaces, near the mucous orifices, and on the 
back of the hands, the scaling is less than over extensor surfaces, in 
regions remote from the mucous orifices, and on the palms and soles. 
The scaling is also less in youth than in advanced years. The scales 
may adhere with considerable firmness to the patch, or may be shed 
freely from the surface, in pronounced cases powdering the clothing of 
the patient or the sheets of the bed upon which he reposes at night. 

Instead of a lustrous white, the scales may display a deep-yellowish 
shade, and, instead of being imbricated, may form a thin continuous 

1 Archiv, 1899, xlvi., p. 433. 

2 Diseases of the Skin, p. 361, and Atlas, plates 25 and 26. 



312 INFLAMMATIONS. 

sheet of exfoliated epidermis. When the eruption is disappearing the 
scales fall, leaving a pigmented or slightly discolored patch of integu- 
ment. 

Psoriasis is essentially a chronic disease, but may present at times 
acute exacerbation, and occasionally begins as an acute process. In the 
acute stages the inflammatory symptoms are more marked ; the lesions 
are of a brighter red color and not so sharply denned as in the ordinary 
forms of the disease ; the scales are also few in number, thin and easily 
detached, and the sensations of burning and itching may be severe. 
When acute, the papules are usually numerous and punctate, and may 
appear on the face ; in other instances the patches are perhaps as large 
as a pullet's egg ; are dark or lurid red over the whole ; are covered 
with a more uniformly constituted, thin, squamous film or sheet of 
semitransparent delicate membrane through which the red glare of the 
patch beneath is visible. This condition may be seen also in young 
persons to whom arsenic has been administered for the relief of the 
disease, with the production of irritative effects. An acute attack may 
come and go as such, but usually it terminates in a chronic form of the 
disease. 

Subjective sensations may be entirely absent in psoriasis, even when 
it is extensive. There is, however, usually slight and occasionally 
severe itching. In acute cases burning and smarting are often present. 
In exceptional cases the subjective sensations interfere with sleep and 
rest ; otherwise the disease does not affect the general health of the 
patient. 

Atypical and complicated forms of psoriasis 1 occur in which the 
character of the lesions is modified considerably. Rarely the scales 
may be heaped up in the centre in the form of an oyster-shell, pro- 
ducing what is termed psoriasis rupioides or psoriasis ostreacea. In a 
few instances the accumulated scales have assumed the appearance of 
a cutaneous horn. Hypertrophy of papillae may produce wart-like 
lesions, designated as psoriasis verrucosa (Besnier, Kaposi, Crocker). 
The scales may be slightly greasy and the surface beneath exhibit a 
trace of moisture, making the diagnosis between psoriasis and eczema 
seborrhoi'cum difficult if not impossible ; indeed the two conditions may 
be associated. Occasionally, in moist situations, on the sensitive skins 
of children, or as an effect of local irritation or infection, the patches 
may be inflamed acutely and indistinguishable from ordinary eczema. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which forms it is difficult to determine whether 
the two disorders coexist or the one has assumed the features of the 
other. In these cases there may be itching and infiltration of the skin, 
with vesicular and other lesions foreign to psoriasis, and a catarrhal 
discharge. 2 

Cavafy, 3 Kusnitsky, 4 and others report cases in which psoriatic 

1 Beyer reviews the subject and attempts a classification of reported cases. Wien. 
klin. Wchnschrft, 1901, xiv., p. 805. 

2 The causes of moist forms of psoriasis are considered by Benassi, Giorn. ital., 1901, 
xxxvi., p. 427 (abstr. in Monatshefte, 1901, xxxiii., p. 460). 

3 Cited by Crocker, 4 Archiv, 1897, xxxviii., p. 405. 



PSORIASIS. 313 

lesions, though numerous, were limited to one side of the body. We 
have had such a case in which the psoriatic lesions were limited to the 
site of a linear nsevus. 

The sequelae of psoriasis are, as a rule, nothing more than a transi- 
tory pigmentation, bat cases are reported in which involution of the 
lesions has been followed by superficial scars (Crocker, Hutchinson), 
keloid formations (Anderson, Purdon, Crocker), persistent deep pig- 
mentation (Crocker), or permanent achromia (Hallopeau, 1 Rille 2 ). In 
some cases these unusual sequelae were due undoubtedly to treatment. 
A few instances have been reported by J. C. White, 3 Hartzell, 4 and 
others, in which epithelioma has followed verrucous lesions which 
developed upon psoriatic patches. Some, possibly all, of such changes 
were due, as suggested by Hartzell, to previous long-continued use of 
arsenic for the psoriasis. When extensive, and especially after per- 
sisting for a number of years without amelioration, psoriasis may lose 
its distinguishing features and assume all the characteristics, both 
clinical and pathological, of dermatitis exfoliativa. 

Etiology. — The causes of psoriasis are not known. Sex, social con- 
dition, and occupation evidently play little or no part in the etiology. 
The disease is common, comprising nearly 4 per cent, of all cutaneous 
affections reported in America. The disorder occurs most frequently in 
the second and third decades of life, but no age is exempt. It is un- 
usual for the first attack to appear after forty-five, and the disease is 
uncommon under ten and rare under three years of age. Rille 5 reported 
a case in which the disease appeared in an infant six days old. Other 
cases in infants less than one year old have been reported by Neumann, 
Kaposi, and others. Benassi 6 reports fourteen cases between the ages 
of sixteen months and ten years. Heredity is seemingly a factor in a 
considerable number of cases, in so far as inherited predisposition or 
susceptibility to psoriasis is concerned ; but direct transmission of the 
disease itself by inheritance has not been demonstrated. A family 
history of psoriasis is the exception rather than the rule. Several 
careful observers, however, have believed that the disease often is 
hereditary. 

The disease apparently bears no definite relation to any one systemic 
condition. It appears in individuals who are apparently in perfect 
health as well as in the delicate and in those ill of other disorders. 
Defective assimilation and elimination, such as exist in gout, rheu- 
matism, and other arthritic disorders, as well as in plethoric and over- 
fed individuals, certainly exercise an unfavorable influence on psoriasis. 
Associated with such conditions psoriasis is usually indolent in type 
but exceedingly persistent, unless the systemic condition be improved. 
In the neurotic and poorly nourished, psoriasis is also persistent, but 
usually with more acute symptoms. The disease has been attributed 

1 Annates, 1898, s. iii., ix., p. 690. 

2 Ibid,, 1901, s. iv., ii., p. 80 (report of ten cases ; discussion). 

3 Amer. Jour. Med. Sci., 1885, lxxxix., p. 163. 

4 Ibid., 1899, cxviii., p. 265. 

5 Jour. Mai. cutan., 1899, xi., p. 385. 

6 Giorn. ital., 1903, xxxviii., p. 99 (abstr. in Monatshefte, 1903, xxxvi., p. 674). 



314 INFLAMMATIONS. 

to fright, shock, and other neurotic conditions. 1 Acute toxsemias of 
various origins have been followed by an outbreak of psoriasis in 
individuals predisposed to the disease. 

The possible contagiousness of psoriasis is suggested by the clinical 
histories of a few cases. Many attempts to transmit the disease by 
direct inoculation have failed, but Destot 2 apparently succeeded in 
inoculating himself from an infant with vaccinal psoriasis, and Lassar 3 
succeeded in producing a disease of the skin in rabbits by rubbing into 
various portions of their bodies scales, blood, and lymph removed from 
psoriatic patches of a male patient. The disease thus induced is said 
to be capable of transmission to other animals. Campana, Tommasoli, 
and other Italian observers have repeated these experiments, with the 
result of reaching the conclusion that psoriasis is produced by a parasite 
as yet unrecognized. 

The fact that psoriasis frequently has followed vaccination, 4 tattoo- 
ing, 5 and other local injuries of the skin, has been held by some to be 
an argument in favor of the parasitic origin of the disease. It has 
long been known, however, that in psoriatic subjects lesions maybe 
developed artificially in the lines of mechanical irritation. In this way, 
figures in the shape of anchors, crosses, hearts, etc., have been pro- 
duced on the skin of psoriatic patients, one of whom has been inge- 
niously photographed by Fox, of New York. 6 

Gowers reports the artificial production of psoriasis by the internal 
administration of sodium biborate. (Consult the section on Derma- 
titis Medicamentosa.) Further evidence would be required to prove 
that these results differed to any appreciable extent from those recog- 
nized in any squamous dermatitis produced by an ingested drug. 

The distribution of psoriatic lesions suggests that the disease may 
be due largely to exclusion of sunlight from those portions of the body 
covered with the clothing and the hair. Certain it is that in exceptional 

S cases only are the hands involved or the face is attacked at a distance 

from the line of the hairs upon the brow and bearded region (sides of 
the nose, cheeks, temples). It is likewise true that after exposure of 
affected areas to abundant sunlight, not only when patients are treated 
intentionally by such exposures of the nude body to light in hospitals 
and in private practice, but in occupations which necessitate the same, 
beneficial results often are marked. 

In winter and in cold countries psoriasis is much more prevalent 
than in warmer seasons and climates. Finally in a considerable 
number of individuals, displaying through life unchanging patches in 
which the characteristic symptoms are the same year after year, the 
ailment would seem more properly to be classed with the deformities 
than with the diseases of the skin. 

Pathology. — The pathogenesis and the proper interpretation of the 

1 Of. Balzer, Annales, 1902, s. iv., ih\, p. 639; Audrv, Jour. Mai. cutan., 1900, 
xii., p.' 345 ; and Weidenfeld, Archiv, 1903, lxiv., p. # 359. 

2 Review of the case by Hallopeau, with discussion, Annales, 1901, s. iv., ii., p. 337. 

3 Deutsche med. Zeitg., 1885, No. 93. 

- Weinstein, Brit. Med. Jour., 1902, i., p. 271 {resume of twenty-four cases). 

5 Bettmann, Munch, med. Wchnschrft., 1901, xliv., p. 1597. 

6 Photographic Illustrations of Cutaneous Diseases, New York. 



PSORIASIS. 315 

histopathological changes in psoriasis are unsettled problems. Many 
cases suggest a trophoneurotic or vasomotor origin ; others appear to 
be toxic and dependent on systemic conditions. The most plausible 
theory and the one that now seems to have the largest number of sup- 
porters is that the disease is due to some as yet undiscovered parasite, 
implanted on susceptible soil. 

Lang l described a fungus which he named " epidermophyton," and 
which he believed to be the cause of psoriasis. His findings were 
confirmed by Wolff and Eklund. 2 Weyl, who believes that psoriasis 
is due to an inherited weakness of the nerve-centres, saw Lang's 
" brood cells/' and regards them as myelin-like exudations. Hies 3 
and others find the bodies described by Lang to be artificial products, 
not spores. It is possible that these bodies are the same as those 
which Crocker describes as " minute circular bodies which lie in loose 
clusters between the separate layers/' and which, by the aid of modern 
technique, Munro, 4 Kopytowski, 5 and others have shown to be leuco- 
cytes situated between the lamellae of the psoriatic scales. 6 The two 
last-named observers state that accumulations of leucocytes which they 
call " dry abscesses" exist between the outermost cells of the horny layer, 
before the appearance of other changes in the epidermis or corium. 
They look upon this fact as almost conclusive evidence of the parasitic 
origin of the disease, but were unable to demonstrate the parasite. 
Robinson, 7 who studied lesions in all stages of development, Thin, 
Jamieson, Tilbury Fox, and others believe the process begins with a 
hyperplasia of the rete which is followed by inflammatory changes in 
the corium. Other investigators of the earliest lesions, including 
Crocker and Verrotti, 8 believe that the pathological process begins as 
a circulatory disturbance in the corium, and that the epithelial changes 
are secondary. 

The histopathology of the disease has been studied by many 
other observers, including Hebra, Kaposi, Bosellini, Jarisch, and 
Schiitz. The corium, especially in the papillary and subpapillary 
portions, shows evidence of subacute or chronic inflammation. There 
are vascular dilatation, moderate oedema, and infiltration of polymor- 
phonuclear and small round cells, which is most marked about the 
vessels. The papillae are much elongated by the pressure from the 
interpapillary prolongations of the rete. The rete shows a marked 
hyperplasia, especially of the interpapillary processes, the number of 
cells immediately over the papillse, however, being fewer rather than 
in excess of the normal, a fact which accounts for the readiness with 
which the papillae bleed on removal of the scales. There is some 
intercellular oedema, the transitional layers are partially or wholly 

1 Vierteljahr., 1878, xv., p. 346. 

2 Annales, 1885. 

3 Vierteljahr., 1888, xv., pp. 521,685, 871 (review of previous reports on pathology 
of psoriasis, with bibliography). 

4 Annales, 1898, s. iii., ix., p. 961. 

5 Ibid., 1899, s. iii., x., p. 705. 

6 Sabouraud states that the scales of many superficial inflammations show leucocytes 
and coagulated serum between the lamellae (Jour. Cutan. Dis., 1903, xxi., p. 61). 

7 N. Y. Med. Jour., 1878. 

8 Annales, 1903, s. iv., iv., p. 633 (bibliography of recent literature). 



316 INFLAMMATIONS. 

absent, and the process of cornification is incomplete, the outer cells 
retaining their nuclei. 

The accumulation of leucocytes between the lamellae has already 
been mentioned. The presence of air between the cells forming the 
scales gives the latter their peculiar silvery-white appearance. 

Diagnosis. — The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical form of the eruption that awakens doubt. 
The diagnostic features of the common types are summarized in the 
first paragraph under the heading of Symptoms. 

Eczema. — Eczema and psoriasis differ in a striking manner with 
respect to their sites of predilection and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous out- 
lets, the flexor faces of the joints and limbs, the crevices, folds, pockets, 
depressions, and protected angles of the skin. Psoriasis elects the 
posterior surfaces of the body, avoids the vicinity of the mucous out- 
lets, spreads abundantly over the extensor aspect of the joints and 
extremities, and enjoys the regions of pressure and friction, as the 
skin over the patella and the olecranon process of the ulna. Psoriasis, 
covering the vertex and scalp, lingers at the brow, where its scaly 
thatch stretches from side to side close to the line of the hairs, and 
creeps more indistinctly down the face on either side in front of the 
ear, reluctant to spread over the cheeks, nose, and lips. Eczema 
easily escapes from the scalp to the nose, lips, or chin, or lurks in the 
folds of the pinna of the ear. Psoriasis will cover the back and reach 
forward in front by almost symmetrically disposed parallels in the 
direction of the ribs, while eczema sweeps between and beneath the 
breasts or around the nipple. Psoriasis usually spares the hands and 
the feet, which eczema punishes. 

In individual patches eczema will be recognized by its severe itch- 
ing ; by the scratching it excites ; by the history of moisture, dis- 
charge, and crusting ; by its ill-defined outline ; by its asymmetrical 
disposition, except upon the similarly irritated hands and feet ; and by 
the fewer, more yellowish, smaller, and less lustrous scales which char- 
acterize its squamous varieties. In squamous eczema, moreover, the 
areas are as a rule larger, more irregular in shape, fewer in number, 
and the less perfectly defined outline does not show the small round 
plaques which unite to form the larger psoriatic areas. In sebor- 
rhoeic eczema the scales are smaller, greasy, and less abundant. The 
surface beneath is moist or oily, shows no bleeding points, and is 
less reddened than in psoriasis. The lesions are most numerous on 
the scalp, over the sternum, and between the scapulae, and rarely are 
found on the elbows and knees. 

Seborrhea. — This disease could only be confounded with psoriasis 
of the scalp ; but the last-named affection is, in the vast majority of 
cases, exhibited also in patches upon other portions of the body on 
which seborrhcea is never seen. Seborrhcea of the scalp also occurs in 
usually diffuse forms, the surface beneath the crusts being rather 
anaemic and pallid in appearance, not bleeding readily, as in psoriasis. 



PSORIASIS. 317 

The crusts, too, in seborrhoea, are distinctly fatty and greasy when 
rolled between the fingers, and have a dirty-yellowish hue, rarely 
recognized in the whitish scales of psoriasis. In psoriasis the hairs are 
not progressively loosened and gradually thinned as in seborrhoea. 
Lastly, seborrhoea (usually in the form of seborrhceic eczema) may 
fringe the line of the hairs at the brow, and even form a band an 
inch or more in width, but the advancing border does not show the 
outlines of the small lesions of psoriasis. 

Syphilis. — Psoriasis in many cases greatly resembles the squamous 
and papulo-squamous syphilides. The necessity for a clear recognition 
of either disease occurring in suggestive patches is often of the highest 
importance. 

In syphilis the greatest aid will be obtained by a history in both 
sexes, of infection, adenopathy, and mucous patches; and in women 
of abortions, miscarriages, or stillbirths. Psoriasis is a singularly uni- 
form disease; syphilis is decidedly multiform in its manifestations. 
Syphilitic patches are less symmetrical, more elevated at the edge, and 
the scales with which they are covered are fewer, smaller, and dirty 
w T hitish rather than lustrous in color. Their circular outline is often 
abruptly broken by gaps, with the result of producing semilunar and 
small arc-shaped segments. In syphilis the eruption is less generalized, 
and shares with other syphilodermata the brownish and purplish hues 
of the skin beneath, lacking the vivid redness and pinkish red of many 
non-syphilitic lesions. The scales of many of the syphilides which 
resemble psoriasis partake of the character of crusts, being agglutinated 
by pathological exudations from the patch; they are rarely so exclu- 
sively squamous as in psoriasis. In syphilis the tendency of the patch 
is to exhibit an affected surface somewhat beyond the line of the scales ; 
in psoriasis the scales more frequently reach beyond the border of 
the affected epidermis beneath. The squamous syphiloderm of the 
palms and soles often occurs only in these localities. Psoriasis is 
extremely rare in such situations, and is not limited to these regions 
exclusively. A psoriasiform circlet limited to the region of the mouth, 
nose, or chin will generally prove to be syphilitic. The disease which 
has for a long time persisted in the production of squamous patches can 
generally be demonstrated to be psoriasis, as syphilis changes its type 
in the course of months. 

Pityriasis Rosea. — In this disease the patches are more oval than 
circular, the scales much finer, and on their removal no bleeding 
points are seen. The centre of the patch is usually tawny or salmon 
colored. The disease is much more superficial, less inflammatory, 
and much more rapid in its career than psoriasis. Complete involu- 
tion is accomplished usually in a few weeks and recurrences are rare. 

Lichen Planus. — The primary lesions in lichen planus are very 
minute, flat, angular papules which as individuals rarely become as 
large as the cross-section of a small pea. The larger areas are formed 
always by grouping and coalescence of small papules. Instead of 
presenting distinct scales, the lichen planus papule is covered with a 
thin horny layer giving the papule a glazed or varnished appearance. 
There is a tendency to linear arrangement of the lesions, and when 



318 INFLAMMATIONS, 

these coalesce to form larger areas the latter are commonly linear or 
angular in outline. The larger papules and patches in lichen planus 
have a characteristic purplish or violaceous hue, which never is seen 
perfectly in psoriasis. The favorite sites of lichen planus are the 
flexor surfaces of the wrist and forearm, and the leg above the ankle. 
It is rarely conspicuous on the elbows, knees, and other regions com- 
monly affected by psoriasis. 

Pityriasis rubra pilaris (lichen ruber acuminatus) is a comparatively 
rare disorder and has for primary lesions fine, pointed, scale-capped 
papules which do not enlarge peripherally, but form larger areas solely 
by the coalescence of many small papules, some of which can be de- 
monstrated at the borders of the larger areas. The characteristic cir- 
cular areas and the typical scales of psoriasis are wanting, and there 
is frequently some impairment of the general health. In exceptional 
instances, however, the two disorders may progress to the formation of 
a generalized or universal exfoliative dermatitis, in which it would be 
impossible from clinical or histological examination to state in which 
of the two disorders the final condition originated. 

Lupus Erythematosus. — In the rare cases in which psoriasis appears 
on the face without characteristic lesions elsewhere, the picture might 
suggest an atypical lupus erythematosus with scattered lesions. The 
scales of lupus erythematosus, however, are scanty, firmly adherent, 
yellowish, and attached to the orifices of the sebaceous follicles. 
There is also a bluish and violaceous tint to the red patch of lupus 
erythematosus, and lesions which have undergone involution may 
leave the characteristic atrophic or stippled scars. 

Tinea Circinata. — In ringworm of the body there are as a rule 
fewer patches, and these are more distinctly circular. They rarely 
attain a diameter of two inches without showing a clearing centre 
and a slightly elevated border covered with furfuraceous scales. The 
discovery of the fungus will establish the diagnosis. 

Favus of the scalp might be mistaken for psoriasis of the same re- 
gion, but the occurrence of sulphur-colored, cup-shaped crusts, the 
existence of the parasite, the lustreless and brittle condition of the 
hairs, the presence of irregular areas of alopecia or of reddened scar- 
tissue, and a possible history of contagion will insure identification of 
favus. In psoriasis, too, the hairs usually are attached firmly in their 
follicles, while they are loosened in favus. 

Treatment. — Though it is very unusual to see cases in which 
psoriatic lesions cannot be removed temporarily, the disease often 
returns, and is exceedingly resistant to treatment. A method which 
is successful in a given case may fail in the next ; indeed, a method 
which gives prompt relief in a given case at one time may fail utterly 
in subsequent attacks of apparently the same nature. The involution 
of the disease under treatment is, as a rule, not rapid, and a chosen 
method should not be abandoned until it has been given a thorough 
trial. 

Systemic Treatment. — The general condition of each patient must 
be ascertained and given due consideration in the treatment. There 



PSOBIASIS. 319 

are many cases of psoriasis in which treatment will prove unsuccessful 
until an accompanying systemic disturbance is recognized and given 
proper attention. On the other hand, when the health, habits, and 
surroundings of the patient are normal, it is better to give local treat- 
ment a thorough trial before resorting to arsenic and other drugs 
which are supposed to have a specific action, 

When, as in the anaemic, the debilitated, the neurotic, the gouty, 
or the rheumatic, a systemic disorder is demonstrated, the indica- 
tions for treatment are clear. The doubtful cases are those in which, 
after careful study, no definite systemic disturbance is discoverable. 
Psoriasis occurs not infrequently, and is often especially persistent 
in individuals who may be classed as fleshy, plethoric, or overfed, 
without other evidences of ill-health. In such cases a restricted diet, 
increased elimination, with possibly the administration of an alkali, 
are effective aids to local treatment. Some writers advocate such 
measures in all cases unless they are contraindicated by anaemia or 
other conditions calling for increased nutrition of the body. 

The diet should be simple and nutritious. In most instances meat, 
sweets, pastry, hot breads and hot cakes, and highly seasoned foods 
should largely or wholly be avoided. Vegetables and fruit may be 
eaten freely. In acute conditions, when the subjective sensations are 
annoying, the diet should be practically that recommended for acute 
stages of eczema. Alcohol, coffee, tea, and tobacco should be inter- 
dicted or used in moderation only. Passavant, however, claims to 
have cured himself and others by an exclusive diet of meat. 

Among the remedies supposed to have a specific action upon 
psoriasis, arsenic enjoys the highest rank. In some cases prolonged 
administration of arsenic gives temporary or even permanent relief; 
in a large proportion of patients, however, carefully selected as fit 
subjects for this therapeutic agent, it will prove utterly valueless even 
in the most skilled hands. Moreover, it is not possible to determine in 
advance what cases will* yield to arsenic, and even with a given individ- 
ual the drug may be of great value at one time and at another without 
effect. Recognizing these facts, the wisest course is not to employ 
arsenic at first, but to delay its administration in any case until local 
treatment has been given a thorough trial. 

Arsenic is valuable chiefly in persistent cases in which the lesions 
have ceased to enlarge. It is unsuited for all cases of psoriasis occur- 
ring with rather acute symptoms, such as subjective sensations and 
unusually vivid redness of the patches. It should not be given when 
the disease is in process of evolution, and, therefore, not in psoriasis 
punctata and guttata, unless the lesions have long been limited to 
patches of the sizes to which these names are given. For the same 
reasons it is often objectionable in the psoriasis of the young, for, 
though the drug is usually well tolerated in early periods of life, it is, 
unfortunately, in the young in whom the disease is also most often 
^encountered in its progressive stages. 

The following rules for the administration of arsenic are in general 
to be observed : It should be given with or immediately after the 
ingestion of food, so that it may be commingled with edible substances 



320 INFLAMMATIONS. 

in the stomach. It should be given at first in small doses which are 
to be increased cautiously. The possibility of the production of toxic 
effects should be remembered, and on their appearance the remedy is to 
be given in a smaller dose, and not completely discontinued unless 
such a course be imperative. 

Individuals not infrequently possess a marked idiosyncrasy against 
arsenic. Cases are seen also in which the administration of arsenic 
for psoriasis is followed by acute exacerbation of the disease with 
decided aggravation of the subjective symptoms. Even in cases in 
which arsenic ultimately proves of value, no results may be achieved 
for a number of Aveeks. The value of arsenic, therefore, in a given 
case cannot be tested with a course of less than three months. The 
prolonged use of large doses of arsenic has been followed in many in- 
stances by palmar and plantar hyperkeratosis, and in a few instances 
by verrucous growths, some of which have become epitheliomatous. 1 
Continued use of arsenic is capable also of producing more or less 
generalized pigmentation with or without a diffuse hyperkeratosis. 

The preparation of arsenic usually employed is Fowler's solution, 
the exhibition of which should always be begun in doses of from ^ 
minim (0.033) to 3 minims (0.20), this amount to be contained in a 
solution of fixed and relatively large dose, such as a teaspoonful of 
infusion of peppermint, wine of iron, dilute syrup of gentian, of 
orange-blossoms, or compound tincture of cardamom with w r ater. When 
only remedial effects are obtained, such as diminution of the scaliness, 
the dose may steadily be continued without change for long periods 
of time, and usually with advantage for some time after the symptoms 
of the disease have disappeared entirely. When, without the pro- 
duction of toxic effects, the eruption seems unaffected by treatment, 
the arsenic may cautiously, and always under the direction of the 
physician only, be pushed until 10 or more drops of Fowler's solution 
are administered at a dose. Other preparations of arsenic may be 
used. A solution of sodium arseniate is preferred by Stelwagon in 
cases of weak digestion. Arsenious acid may be given in doses vary- 
ing from 4L to 2V (0.0016-0.0033) grain in pill or tablet, or in the form 
of the Asiatic pill, the formula for which is given in the section on 
General Therapeutics. This pill is less likely to be tolerated well 
than Fowler's solution, but cases are on record in which a psoriasis 
which proved rebellious under the administration of other forms of 
arsenic, yielded to the Asiatic pill. 

Sodium cacodylate, an organic compound of arsenic containing 55 
per cent, of arsenious acid, has been recommended and used largely 
by some of the French dermatologists. It is supposed to be less 
disturbing to digestion and to be comparatively free from the danger 
of producing toxic symptoms. The dose recommended is from \ to 
3 grains (0.033-0.2), three times a day. That it is not safe in large doses 
was demonstrated by the case of Murrell, who gave a patient 1 grain 
(0.06), 2 three times a day, until, on the eleventh day, there suddenly 
appeared serious symptoms of intoxication. Dermatitis following its 

1 Cf. White and Hartzell, loc. cit. 

2 Lancet, 1900, ii., p. 1923. 



PSOEIASIS. 321 

use is reported by Balzer and Griffin. 1 We have used the drug in a 
few cases in doses varying from -^ to J (0.004-0.033) grain, three times 
a day, but have not found it of greater value than the other prepara- 
tions of arsenic. 

Satisfactory results often follow the internal administration of mer- 
curous iodide in i grain (0.013) doses after meals. The remedy is 
given, not in cases in which a syphilitic taint is suspected (for psoriasis 
is not a manifestation of syphilis), but as an alterative. It is believed 
to be effective in consequence of its special effect on the liver. In 
some patients it seems to have little value. 

Crocker advises the use of sodium salicylate and salicin in all forms 
of psoriasis, but especially during periods of active development of 
the disease, when arsenic usually is harmful. We have found these 
remedies of value in a number of cases. Salicin is the better of the 
two preparations, as it interferes less with digestion. It may be 
given in doses ranging from 10 to 20 grains (0.65-1.33), three times a 
day. Haslund recommends potassium iodide, increased from the 
smaller to the largest tolerated doses. As many as 600 grains of the 
iodide have been administered by this method per diem ; it is of occa- 
sional service. The wine of antimony in 5 to 10 minim doses ; chry- 
sarobin, \ grain (0.01) rubbed up with sugar of milk, three times daily ; 
potassium bromide and sodium iodide have also been administered 
with reported success. 

In plethoric or rheumatic patients local treatment often is rendered 
more effective by the internal administration of liquor potassse, potas- 
sium citrate or acetate, or sodium bicarbonate in doses of from 10 to 
30 grains (0.65-2), taken with large quantities of water three times a 
day. In the gouty state with excess of urates in the urine Robinson 
advises : 

R 



Potass, acetat., 


l'y, 


30 


Spts. asther. nit., 


fgss; 


15 


Vin. colchici, 


f3ij; 


8 


Syr. aurantii, 


fSJss;. 


45 



M. 

Sig. A dessertspoonful three times daily in water after meals. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remember- 
ing that arsenic is superior to them all. Phosphorus, tar, copaiba, can- 
tharides, colchicum, and pilocarpine have at times a feeble transitory 
influence over the patches of the eruption, but their employment will 
disappoint far more often than satisfy. The treatment of psoriasis by 
the administration of extract of the thyroid gland practically is aban- 
doned as fruitless of desirable results. 

External Treatment. — The influence of climate in inveterate psoriasis 
should never be ignored. Many patients who suffer from repeated re- 
lapses of the disease are worse in winter, and are either better or entirely 
free from the eruption in summer. In mild climates in which the tem- 
perature is uniformly registered at or near a point of maximum comfort 
for the skin this disease is both infrequent and less severe. Given an 

1 Annales, 1897, s. iii. ? viii., p. 732. 



322 INFLAMMATIONS. 

equable climate many patients obtain prompt relief at the seashore, 
while others improve rapidly under the influence of the dry atmosphere 
of higher altitudes. The majority of patients with psoriasis, however, 
are unable or unwilling to seek a change of climate for the relief 
of a disease which at worst is an annoyance. In cold and change- 
able climates some patients add greatly to their comfort by varying 
their dress to meet the exigencies of the weather and thus keeping 
the skin at as even a temperature as possible. When there is much 
itching, cotton or linen underwear next the skin is, as a rule, most 
comfortable. We have found some patients who could free themselves 
from the disorder by giving the affected parts a sun-bath daily or 
several times a week. 

A treatment, practically based on the same principle as that of the 
sun-bath, which we have found very effective in removing psoriatic 
lesions, is that of radiotherapy. Of 70 cases that we have treated 
with the method, the lesions were removed entirely in 35, nearly 
all removed in 18, and partially removed in 10 ; in 4, the subse- 
quent results are not known ; in 2 generalized cases the eruption par- 
tially disappeared, but new lesions formed so rapidly that no progress 
was made ; in 1 case, that of a neurotic woman, in whom the lesions 
were of the ordinary nummular type, a long course of the treatment 
seemed to make no impression. In the majority of the cases in 
which there was failure to relieve entirely, the treatment could not be 
given regularly or for a sufficient length of time. However, in some 
generalized cases as the original symptoms were removed new lesions 
appeared in adjacent or distant regions of the body. After the re- 
moval of lesions by this method recurrences are apparently some- 
what less frequent than after other local treatments of the disease, 
and as a rule recurrent lesions disappear much more promptly 
under the treatment than do the original patches. One case of in- 
veterate psoriasis which had resisted all forms of treatment for fifteen 
years yielded promptly to a few applications of the x-rays, and has 
not recurred at the end of a year. The treatment by this method 
has given most satisfactory results when the disease has been limited 
to circumscribed areas. We have used a coil with a spark-gap equiv- 
alent of 12 inches, an amperage of from 1 to 3, and a voltage of 
70 ; a moderately soft tube (usually the Muller automatic) showing a 
light so feeble that it could be detected with difficulty in ordinary 
daylight; the distance from lesion to target, 8 to 15 inches; and 
the time of exposure, 3 to 6 minutes. Treatments were given 
twice a week for ten days or two weeks and then suspended. From 
3 to 6 treatments were required on the average to remove the lesions 
from a given area. After the second, and occasionally after the 
first treatment, the subjective sensations were ameliorated decidedly. 
Usually within a week the scaling was less pronounced and involu- 
tion of the lesions progressed gradually, resulting in their complete 
disappearance in from three to six weeks. In the majority of the 
cases no reaction in the way of erythema or dermatitis was produced. 
The lesions themselves are more sensitive to the rays than the sur- 
rounding normal skin, and may show distinct inflammatory reaction 



PSORIASIS. 323 

when the surrounding normal integument displays nothing more than 
a slight erythema. While it is too early to state that the method 
gives more lasting results than other local treatments, it is cleanly, 
and patients who can afford it find it more agreeable and requiring 
less time than the frequent application of ointments or other local 
remedies. The disease as a rule responds so well to short applications 
of feeble light that it is not necessary to push the treatment to the 
point of producing a dermatitis. 

The local treatment of psoriasis requires patience, care, and a cer- 
tain degree of skill. In a large majority of cases a local remedy can 
be found which, when applied with proper care and persistence, will 
remove the lesions completely. This result, however, does not insure 
the patient against recurrences of the disease. The first indication to be 
met is the complete removal of the epidermic scales from the patches, 
which removal is accomplished in various ways. It is preferable 
to secure first their maceration in some fatty substance, such as one 
of the oils, or glycerin, or vaselin, after which the scales may be 
Avashed off with the aid of soap and water, the patient being given 
a general bath if the eruption be extensive. If it be localized, these 
oily or fatty substances may be spread upon pieces of lint or cotton, 
and thus be retained in contact with the skin by a bandage. The 
scales may also be removed rapidly with a dermal curette, if they 
occur in few patches, or if the patches are to be found in totality 
or in part upon some portion of the body in which the disfigurement 
demands special attention, as upon the forehead and the cheeks. The 
squamous masses are also removable with water alone, as after maceration 
of the skin in a bath, or after a profuse diaphoresis, or even after mod- 
erate exudation of sweat, if evaporation of the latter be " prevented by 
covering the affected part with oiled silk or with rubber cloth. Usually 
there is no difficulty in removing these scales, patients often declaring 
that they can themselves cleanse the surface. They ask to be shown 
how to prevent the recurrence of the desquamation. 

Baths play an important part in the subsequent treatment of the 
disease. They may be employed, as by Hebra, so that the patient 
remains in the water for from four to eight hours in the day ; or be 
medicated by the addition of sulphur, tar, or other substances, so as to 
combine a medicative with a macerative effect. In private practice 
these baths are much less available than in hospitals. When the erup- 
tion is generalized and an excessive macerative effect is desired an 
undershirt and drawers, made of soft rubber cloth, may be worn by the 
patient for several hours of the day. The sweating is often profuse, 
and is debilitating to such an extent that the psoriatic skin will rarely 
tolerate the treatment for an entire day, or even for that part of the 
day in which active labor is performed. By this sweating alone it 
will at times be found possible to secure complete disappearance of the 
patches. 

In other more obstinate cases, or in those in which for any reason 
vigorous treatment is indicated, as upon the scalp and face, sapo viridis 
may be employed with advantage in the soap-and-water treatment. 
The spiritus saponis kalinus, 2 ounces (60.) of the soap to 1 ounce (30.) 



324 INFLAMMATIONS. 

of alcohol, may be rubbed briskly over the patches with the aid of a 
piece of flannel or a sponge, and then immediately be washed off with 
the oil and scales in a surplus of hot water, or be left for a time in 
contact with the part. Hebra and Kaposi employed a species of soap- 
paste, made by rubbing into each patch a small quantity of green soap 
to which a little water is added until the proper consistency is obtained. 
These inunctions' are repeated twice daily for six days. The epidermis 
becomes brownish-colored, and in three or four days afterward it exfo- 
liates in lamellae ; then a general bath cleanses the surface. In the 
French hospitals a somewhat speedier method is pursued. On the 
evening of the first day the patient is anointed with green soap, which 
is retained upon the skin during the night. In the morning he takes 
an alkaline bath, and immediately after is thoroughly anointed with 
lard. This course is repeated on the second and third days, after which 
the patient is usually ready for topical medication of the diseased parts. 

For the more obstinate cases in which exfoliation of the epider- 
mis is not readily induced more energetic measures have been adopted, 
such as the local use of salicylic acid in alcohol, 1 drachm (4.) to 4 ounces 
(120.), caustic acid and alkalies, scrubbing the patches with nail-brushes, 
floor-brushes, etc., and the use of clean white sand. 

Once ready for topical medication, the patches may be subjected to 
the local action of the remedy selected for the relief of the disease. 
The choice of a vehicle for the application of remedies is a matter of 
importance. For hospital patients, moderately soft ointments, such as 
lanolin or lard, with or without the addition of cold cream ointment, 
may be rubbed into the patches, which may then be covered with cloths 
spread with more of the same ointment. For such cases, an ointment 
which keeps the surface soft and favors penetration of the reme- 
dies, is usually more rapidly effective than the drier pastes, especially 
when there is much scaling and infiltration. When the patches are 
irritated moderately, and in acutely spreading areas, the protection 
afforded by the paste is often of more value than the closer contact of 
the remedy with the lesion permitted by the soft ointment. But the 
majority of patients with psoriasis are unable to give the time necessary 
for hospital treatment, and remedies must be chosen which will not 
interfere with the usual vocation of the individual. For the scalp 
and other hairy parts, vaselin, or equal parts of vaselin, lanolin, and 
olive oil, are convenient ointment-bases. For the face and hands a 
moderately soft ointment may be used as directed above for hospital 
cases. When the occupation of the patient will permit, the lesions 
may be kept covered with a thin coating of the same ointment during 
the day, or this may be removed entirely and the patches protected 
with a tragacanth-varnish (see section on General Therapeutics), which 
in turn must be washed off at night before applying the ointment. 
For covered portions of the body, the most convenient base is a paste, 
equal parts of vaselin, lanolin, zinc oxide, and talcum making a good 
combination. When the lesions are few in number, the paste may be 
spread on a cloth and applied. In more extensive cases the paste may 
be spread in a thin layer over the patches, which then are covered 
freely with any simple powder. This is patted on with the hand or 



PSORIASIS. 325 

with cotton until a dry surface is formed which does not adhere to 
the clothing. The underclothing next the skin should be of soft 
cotton. 

For circumscribed areas flexible collodion, liquor guttse perchse 
(traumaticin) holding in solution the remedies to be employed, or 
medicated plasters are more convenient and cleanly than pastes or 
ointments. 

Salicylic acid, in paste, ointment, or plaster, in strengths varying 
from 2 to 20 per cent., is often effective, and is free from the disagree- 
able and even dangerous properties of some of the stronger drugs. 
For the face, scalp, and hands there is no better remedy in the majority 
of cases than ammoniated mercury in 2 to 20 per cent, ointment or 
paste. This remedy is cleanly and usually causes the lesions to disap- 
pear ; but it cannot be used over large areas without danger of absorp- 
tion and constitutional symptoms. 

A drug of great value in the treatment of psoriasis is chrysarobin 
(or chrysophanic acid). This is a crystalline powder of the color of 
old gold, insoluble in water, but is dissolved readily in hot alcohol, 
chloroform, benzol, vaselin, and hot fat. It is derived from the " Goa 
powder " of the East Indies, or the " araroba powder " of Brazil, the 
employment of which in psoriasis was recommended first in 1878 by 
Squire, of London. The drug may be applied in strengths varying 
from 2 to 40 grains (0.13 to 2.66) to the ounce (30.) of ointment, paste, 
plaster, collodion, or liquid gutta-percha. It is used occasionally in 
greater strength, but with pure specimens it is liable in larger propor- 
tions to produce disagreeable effects, commonly manifested in a hot, 
itching, swollen, irritable, and erythematous or darkly stained skin, 
stretching with tolerable uniformity in every direction from the surface 
of application. Even in the strength named above it is necessary to 
begin its use with caution, testing it by application first to a limited 
area of integument. The dermatitis produced by the drug usually 
subsides in a few days. 

When chrysarobin produces -its most brilliant effects the psoriatic 
patch, previously denuded of its scales, assumes a whitish and normal 
aspect, contrasting thus somewhat remarkably with the chocolate or 
brownish-black discoloration of the stained skin at the periphery. This 
discoloration, when produced either by the ointment directly or by a 
frequent transfer of its ingredients to other parts by the medium of the 
clothing and the hands, involves also the nails, the hair, and the 
undergarments of the psoriatic patient. Its employment upon the 
face and the scalp is thus largely interdicted. The staining of the 
skin and its appendages disappears entirely in time, but always 
slowly. 

Chrysarobin is of value chiefly in chronic, persistent cases in which 
milder remedies fail. In the acute forms there is great danger of 
producing dermatitis with the drug. When the lesions are numerous, 
or in large areas, the most rapid results are obtained by applying the 
remedy in the form of a soft ointment which may be rubbed thoroughly 
into the patches once or twice a day. The surplus ointment may be 
wiped off and the skin covered with a dusting-powder. Used in this 



326 INFLAMMATIONS. 

way the drug stains the underclothing and the skin and is more liable 
to produce a dermatitis. For circumscribed areas, chrysarobin may 
be applied in liquor guttse perchse (traumaticin). After the scales have 
been removed thoroughly, a film of traumaticin is applied with a 
brush or a swab, and allowed to dry. Several coats may thus be put 
on within a few minutes. The dressing usually will stay in place 
several days. When it becomes loose, it should be removed and a 
fresh dressing applied. Instead of traumaticin, collodion may be used. 
An effective combination, suggested by Fox, is 10 parts each of chrys- 
arobin and salicylic acid, 15 of sulphuric ether, and 100 of flexible 
collodion. The following method, first suggested by Besnier, brings 
the drug in closer contact with the lesions and gives more rapid results : 
a solution of chrysarobin in chloroform, 20-40 grains (1.33—2.66) to 
the ounce (30.), is applied to the patches. The chloroform rapidly 
evavorates, leaving the powder adhering to the surface. When a 
sufficient quantity has thus been applied and is thoroughly dry, col- 
lodion or traumaticin is allowed to flow over the patch to produce a 
protecting film. Instead of dissolving the chrysarobin in chloroform, 
it may be mixed with water to form a paste and applied in the same 
manner. Fox uses chrysarobin in a 50 per cent, aqueous solution of 
ichthyol. After painting it on the patches and allowing it to dry, a 
dusting-powder may be used. 

Hallopeau reports cases in which the lesions disappeared when kept 
covered with unmedicated traumaticin. 

Tar is among the most valuable remedies in the local treatment of 
psoriasis. It will, however, accomplish the result desired only when so 
applied that it is tolerated well by the skin. In very young patients, as 
also in those whose skins are tender and irritable, or those suffering 
from any of the acute phases of the disease, it may prove decidedly 
injurious. The rule should be always to employ it at first tentatively 
over a relatively small portion of the affected surface, upon which the 
medicament should remain for several hours, as tar will not in ail cases 
promptly produce its injurious effects. These effects are, subjectively, 
a sense of heat and pain ; and, objectively, heat to the touch, redness, 
and tumefaction. Often black puncta are visible when the tar is lodged 
in the orifices of the cutaneous follicles, simulating thus the "black 
head" of the comedo, a condition termed by Hebra " tar-acne." 

Pix liquida, oil of cade, or preferably oleum rusci may be employed 
in the form of a salve, 1 drachm (4.) of either to the ounce (30.) of 
lard or other fatty basis (lanolin, vaselin, etc.). A thin stratum of this 
ointment several times in the day or merely at night may be painted 
over or well rubbed into a patch denuded of scales. In Vienna a still 
more energetic effect is secured by using soft soap freely over the 
patches while the patient is in the bath, then anointing him with tar, 
and finally returning him to the bath, in which he remains for from 
four to six hours. For localized eruptions, green soap in combination 
with tar and alcohol serves a useful purpose, either in the proportion 
of equal parts of the three ingredients, or by combining them in other 
proportions, as, for example : 



B 



Sig. 





PSOBIASIS. 




Saponis viridis, 


liv; 


120 


01. rusci, > 
Glycerin., j 


aa I] ; 


30 


01. rosmarin., 


3jss ; 


6 


Spts. vin. rectif., 


Oss; 


240 


For external use. 







327 



M. 



Other combinations of service are the " liquor picis alkalinus," the 
formula for which is given in the chapter on Eczema ; or Wilkinson's 
salve/ as modified by Hebra, the latter combining the remedial effects 
of sulphur, tar, and soap, as follows : 

B Sulphur, sublimat, "I ^ _ 

01. rusci [crud. vel. rectifJ ' a 5ss 



Saponis viridis, ) %] 30 

Adipis, J OJ ' 



Cret. praeparat. 
Sig. Wilkinson's salve, modified. 



5 M. 



Where the sensitiveness of the skin to the action of tar has not 
been tested, or when the skin is particularly tender, a small quantity 
of the Wilkinson salve may be added to any simple ointment, or Spen- 
der's ointment of tar (see the chapter on General Therapeutics) may 
be substituted ; afterward 1 drachm (4.) of the oil of tar, or of oleum 
rusci, to the ounce (30.) of oil of almonds or of alcohol, may be 
employed. 

When toleration is established the tar may be rubbed over the 
patches in a pure state with a stiff brush, a procedure preferred in 
some parts of Germany, after which the patient either remains for 
some hours in bed, or is powdered with soapstone and bandaged with 
flannel, so that when the clothing is replaced it may not adhere to the 
tar. Naphtalin, ichthyol, and carbolic acid operate in psoriasis in the 
same way as the tars, but are decidedly inferior to tar. 

Absorption of any tarry compound applied externally may result in 
general toxic symptoms, including fever, vomiting, diarrhoea, stran- 
gury, the elimination of the toxic agent in secretions which are 
blackened by its presence. These symptoms are usually relieved in 
from twenty-four to forty-eight hours after discontinuance of the 
drug. 

Pyrogallol, first suggested as a remedy for psoriasis by Jarisch, is 
inferior to chrysarobin. The fact that several deaths have been reported 
as consequent upon the use of this acid deters many from making trial 
of it in a painless and merely disfiguring disease. It is used in a 10 
per cent, vaselin ointment, is effective though less rapid in effect than 
chrysarobin, is cheaper, is odorless and painless, and it discolors to a 
less extent the sound skin. Both remedies are capable of being 
absorbed from the skin-surface, and of producing constitutional symp- 
toms (pyrexia, strangury, and blackish evacuations) ; but in the case 
of pyrogallic acid only have fatal results followed. 

Kaposi x was the first to employ beta-naphtol (the formula being 
C 10 H 8 O) in psoriasis, as also in eczema. It may be applied in alcoholic 

1 Wien. med. "Wchnschrft., xxxi., pp. 617, 641, 681. 



328 INFLAMMATIONS. 

solution. Following the employment of a 15 per cent, ointment the 
author reported speedy disappearance of psoriatic patches. It did not 
stain the skin, hair, or nails. 

Crocker, of London, similarly uses thymol in ointment, \ scruple to 
\ drachm (0.66-2.) to the ounce (30.) ; and Williamson advises tur- 
pentine, 2 drachms (8.) to the ounce (30.) of olive-oil, with the odor 
corrected by the oil of lemon. 

Circumscribed areas have been treated successfully by the daily ap- 
plication of compresses wet in a 1 : 300 or 1 : 200 solution of potassium 
permanganate (Hallopeau *), or in 70-90 per cent, alcohol containing 
2 per cent, of salicylic acid (Lau 2 ). 

For inveterate cases, Unna and Dreuw recommend the following : 

B Acid, salicylic, 3yss; 10 

Va P s Z., TiridiS ' } »3vj; 25 

Sig. For external use. 



M. 



Blaschko 3 finds Rochard's formula of value in stubborn cases 
which do not yield to chrysarobin : 



R Iodi pur., gr. 10 ; 

Hydrarg. chlorid. mitis, gr. xxvj ; 1 

Vaselin. vel adipis, q. s. ad ^iij 31J ; 100 



M. 



These stronger applications must all be used with caution, and any 
dermatitis produced should be treated with soothing ointments. 

The nitrate, as well as the iodides and oxides, of mercury is applied 
by many practitioners in the form of ointment to patches of psoriasis 
usually few in number and limited in extent. The action of these 
agents, however, is inferior to that of those already named ; and the 
range of their availability being limited, they should be esteemed lightly 
in the topical treatment of the disease. Other articles more recently 
vaunted in the external treatment of psoriasis are : thilanin, which 
seems to possess some value ; hydracetin ; cacodylic acid ; rufigallic 
acid, 10 per cent, in unguent form; cupric oleate ; anthrarobin ; and 
gallacetophenol, 5 to 10 per cent, in salve or in traumaticin. 

Prognosis. — The permanent relief of psoriasis is not insured by any 
treatment of a grave case, though hundreds of patients are permanently 
relieved by even the simplest treatment. The disease often recurs, and 
may do so repeatedly for the greater part of a lifetime. Permanent 
relief, therefore, should never be either predicted or promised in any 
case. Once relieved, it should be the aim of the practitioner to guard 
against all possible recurrences. After relief of any obstinate or re- 
current attack, as also in all inveterate cases, the prognosis is greatly 
improved by removal to a climate suitable for the psoriatic patient. 

1 Annales, 1902, s. iv., iii., p. 518. 

2 Semaine rued., Sept. 13, 1899. 

3 Archiv, 1901, lvi., p. 253. 






> 

h 

Oh 







PITYRIASIS ROSEA. 329 



PITYRIASIS ROSEA. 



(Pityriasis Maculata et Circinata, Herpes Tonsurans Macu- 
losus, Pityriasis Circinata. Fr., Pityriasis rose de 
Gibert, Pityriasis ctrcine et margine*.) 

Pityriasis rosea is a mild febrile disorder of specific character and 
determinate course, in which appears a cutaneous, usually symmetrically 
disposed, exanthem in the form of multiple, circumscribed, superficial, 
roundish or oval-shaped, yellowish and rosy patches, covered with fine 
scales and seated for the most part on the trunk. This disorder was 
recognized and described first by Gibert, 1 and later by Bazin, Horand, 
Duhring, 2 and others. 

Symptoms. — The subjects are commonly young adults, but the 
disease is seen in children and in middle life in both sexes. The out- 
break of the malady may be preceded for a variable time by languor, 
lassitude, inappetence, or a feeling of chilliness. Occasionally the first 
noticeable symptom is the occurrence of mild fever, the body-tempera- 
ture rarely rising above 102° F. There may be slight swelling of the 
submaxillary glands and of those of the neck. General adenopathy is 
reported. In acute cases there may be distinct congestion of the 
fauces. 

In some, Brocq believes in all, cases the general outbreak is pre- 
ceded for a week or ten days by a single lesion situated usually at the 
side of the trunk. The eruption often escapes recognition for a time 
after its appearance on account of its sparseness or the trifling degree 
of pruritus it arouses. When fully developed, it is characterized by the 
conspicuous appearance over large surfaces of the trunk, especially 
upon the integument covering the clavicles, the ribs, and the scap- 
ulae, rarely on the exposed face and hands, of numerous pinhead- 
to small-coin-sized, circumscribed, roundish or oval-shaped, slightly 
elevated, macular or maculo-papular lesions. These lesions may be 
discrete, closely set, or confluent, and instead of being elevated may 
be either on a level with the general surface or slightly depressed, 
with an annular border. They are dry, covered with furfuraceous 
rather adherent scales, and vary in color from a yellow or tawny 
shade to a deep red. The infiltration is slight, and the patch is situated 
superficially. 

The fully formed disks vary in long diameter from the width of a 
finger-nail to three or four centimetres. The oval contour is that 
more often recognized as characteristic of a well-developed lesion, the 
long axis of the disk usually corresponding with the lines of cleavage, 
and the terminal extremities of the oval slightly frayed by the irregu- 
larity with which the fine branny scales are there disposed. A tawny, 
salmon-shade is highly characteristic of the disease, the patch slightly 
enlarging by peripheral extension, and leaving a relatively clear centre. 
The scales have often a silvery grayish color. The eruption may be 
tolerably well generalized, but the face and other exposed parts of the 

1 Traite pratique ties maladies de la Peau, Paris, 1860. 

2 Amer. Jour. Med. Sci., 1880, lxxx., p. 359. 



330 



INFLAMMA TIONS. 



body usually escape, though the scalp may be involved. In the latter 
event the hairs are unaffected. 

The variations exhibited by the exanthem in this affection are dis- 
tinct, but are scarcely ever sufficient to mask the characteristic appear- 
ance of the oval or circular plaques over the neck, the arms, the ab- 
domen, or the extremities, sometimes first appearing over the latter 
and extending thence to the trunk. At times a retiform expression is 
given to the picture by coalescence of the patches. There may be 
moderate itching with nocturnal exacerbation, but the usual type of 
the disease is mild. The affection runs its course ordinarily in from ten 
days to six weeks, but may last several months if new lesions continue 
to appear. Recurrences are rare. 

Etiology. — The causes of this disease are obscure. Bazin believed 
it occurred chiefly in lymphatic and scrofulous patients. Most patients 
have light hair and delicate skins, and have been enfeebled by great 
physical fatigue or by overtaxation in school. Profuse perspiration 
has been assigned as a cause by Horand. Though no true epidemics 
are reported, and positive evidences of contagion are wanting, it occa- 
sionally happens that the disease is so unusually prevalent during a 
few weeks in a given locality as to suggest an epidemic ; there are 
also instances in which two members of the same family were affected. 
(Crocker, Zeisler, Fordyce, G. H. Fox.) It is possible the disorder 
is feebly infectious and allied to the exanthemata. 

Pathology. — The histopathology of the disease has been studied by 
Unna, Hollmann, 1 and Sabouraud. 2 The changes begin apparently in 
the papillary body and the subpapillary layer of the cutis, and include 
a dilatation of the vessels, perivascular cell-infiltration, and oedema. 
As the disorder progresses these changes are more marked, espe- 
cially the perivascular cell-infiltrate. The rete shows decided intra- 
cellular and intercellular oedema and proliferation of the prickle-cells, 
especially in the interpapillary portions. As the disease approaches 
its acme minute vesicles, not visible on macroscopic examination, form 
beneath the horny layer, which later is exfoliated. Sabouraud states 
that these vesicles are found in the outer layers of the epidermis much 
as the " dry abscesses " described by Munro are formed in psoriasis. 
The absence of polynuclears (phagocytes) in the vesicles leads him to 
believe the disease is not parasitic, but a vesicular erythema of toxic 
origin. 

Diagnosis. — When fully developed and presenting characteristic 
lesions with a yellowish -brown centre and a pale frayed border cov- 
ered with fine scales, the diagnosis is simple, especially if a number 
of the oval patches show the usual arrangement with the long axes 
in the lines of cleavage. When the lesions are numerous but less per- 
fectly developed, and of the smaller, maculo-papular and more inflam- 
matory type, the disease may resemble a maculo-papular syphilide so 
closely as to defy even the expert. In the absence of all other evi- 
dences of syphilis, delay of a few days usually will permit the develop- 
ment of either the typical oval lesions of pityriasis rosea, or of other 

1 Archiv, 1900, li., p. 229. 

2 Abstr. in Jour. Cutan. Dis., 1903, xxi., p. 55. 



PITYRIASIS ROSEA. 331 

signs of syphilis. Ordinarily the lesions of pityriasis rosea are infil- 
trated less, are of a brighter but paler tint, and are more rapid in evo- 
lution than those of syphilis. The congestion of the fauces in the 
former is of a bright-red color and diffuse, while that of syphilis is 
dull red and circumscribed. 

In eczema seborrhceicum the slow development of the lesions, their 
distribution over the scalp, sternum, and between the scapula? rather 
than on the trunk along the lines of cleavage, the coarser and more 
abundant scales, the fine papules on the one hand, or large areas on the 
other, and the absence of typical oval lesions of pityriasis rosea, will 
establish the diagnosis. Cases are noted occasionally in which the 
differential diagnosis is exceedingly difficult or almost impossible, and 
which suggest an intermediate stage between the two disorders. 1 

In psoriasis the patches are infiltrated, elevated, and more sharply 
defined. The abundant, imbricated, and silvery-white scales, the 
bleeding points beneath, and the distribution of the lesions, are points 
of value in the diagnosis. 

In ringworm of the glabrous skin the lesions are rarely so numerous 
or so symmetrically distributed. The areas are more definitely cir- 
cular, more circumscribed, and often display minute vesicles at the 
periphery. The areas showing clearing centres are larger than those 
of pityriasis rosea. Finally, the fungus can be demonstrated in the 
scales. 

Treatment. — Pityriasis rosea is, as a rule, a self-limited disease in 
which the duration and career vary greatly in different cases. Conse- 
quently it is difficult to judge of the value of treatment in a given 
case. Systemic treatment should be varied to meet the indications in 
each instance. The febrile and throat symptoms, if present, should 
receive proper attention. In many cases no internal treatment is 
required. Crocker believes the course of the disease is shortened by 
giving salicin in 15 grain (1.) doses three times a day. Locally, mild 
sulphur or other antiseptic ointments appear to shorten the duration 
of the disease in many instances. A convenient and simple treatment 
which we have employed with apparently good results in many cases 
is as follows : The patient takes a bath at night before retiring, and 
after drying the skin applies to the areas a weak vinegar or dilute 
solution of acetic acid, and before this dries follows with a 10-15 per 
cent, solution of sodium hyposulphite. In a few moments, after 
the surface is dry, a simple dusting-powder may be applied. In the 
few instances in which itching or burning is annoying, the under- 
clothing should be of silk or cotton, and the surface of the body 
should be kept constantly covered with some adherent powder, like zinc 
stearate. Rarely it is necessary to use soothing, mildly antipyretic 
lotions or ointments, such as are recommended for the early stages of 
eczema. In two of our unusually extensive cases in which itching was 
a pronounced feature, two brief exposures to the .r-rays were followed 
promptly by cessation of subjective sensations and by rapid involution 
of the lesions. 

1 Cf. Besnier, Annales, 1889, s. iii., x., p. 108. 



332 INFLAMMATIONS. 

DERMATITIS EXFOLIATIVA. 1 

(Fr., £rythrodermie exfoliante [Besnier], Dermattte 

EXFOLIATRICE.) 

Exfoliative dermatitis is a disorder in which over considerable por- 
tions or the entire surface of the body the skin is reddened and covered 
with lamellated scales which are exfoliated freely from the surface ; 
the disease may be accompanied by itching or burning sensations, and 
by febrile and other signs of systemic disturbance, and may pursue 
an acute or more commonly a chronic course. 

Some confusion, both as to the names of diseases and as to the dis- 
eases themselves, has existed in connection with the subject of all gen- 
eralized exfoliative cutaneous disorders. More investigation is needed 
before definite limits can be established for several of the dermatoses 
of this class. By some, the term " dermatitis exfoliativa " is held to be 
synonymous with pityriasis rubra. In these pages the term pityriasis 
rubra is restricted to the disease first described under this title by 
Hebra, and Dermatitis exfoliativa is made to include the generalized 
and universal forms of exfoliative dermatitis not properly considered 
in other connection. 

Symptoms. — Aside from the pityriasis rubra of Hebra, cases of 
dermatitis exfoliativa may roughly be subdivided into three types 
according to the mode of origin. The first is practically identical in 
origin with erythema scarlatiniforme, to which subject the reader is 
referred for a description of the early stages. The acute type of scar- 
latiniform erythema may be followed exceptionally by generalized or 
universal exfoliative dermatitis lasting for months or years. The sub- 
acute form of erythema scarlatiniforme not infrequently terminates in 
an exfoliative dermatitis, usually as a result of recurrent attacks. This 
form of the disorder usually undergoes involution in the course of a 
few months or a year or two. The process of recovery is gradual, 
areas of normal skin occurring here and there over the body and 
slowly enlarging peripherally, while the exfoliation over the surface 
of the body in general becomes gradually less pronounced. Eecur- 
rences are, however, not infrequent. 

The second type, to which Erasmus Wilson first applied the name 
dermatitis exfoliativa, may begin insidiously without any manifestation 
of constitutional disturbance, or it may be accompanied by mild febrile 
symptoms which may have been preceded by malaise, languor, or a 
variable period in which the general health has been impaired. 

The eruptive symptoms are a more or less shining and vivid redness 
of the skin in one or several plaques which become in the course of 
a week the seat of numerous fine, bran-like scales. Any region of the 

1 For bibliography, see Bowen, Jour. Cutan. Dis., 1902, xx., p v 548 (report of four 
cases, illustrating four types of exfoliative dermatitis) ; Brocq, " Erythrodermies exfo- 
liantes generalisees," La Pratique Dermatologique, t, ii., p. 548 (reviewof the subject 
with elaborate classification and complete bibliography) ; Bruusgaard, Zeitschrft., 1901, 
viii., p. 571 (report of fatal case, bibliography) ; Luithlen, "Die Dermatitis exfoliativa 
Wilson und das Erythema scarlatiniforme recidivans," Zeitschrft., 1902, ix., p. 24 
(review of reported cases) ; Torok, Mracek's Handbuch, Bd. i., p. 767 (complete bibli- 
ography). 



DERMATITIS EXFOLIATIVA. 333 

body may be affected, though the articular folds of the skin, the genital 
region, the head, and the trunk are most often the seat of the disease, 
which may involve consecutively one part after another until in a week 
or a fortnight the whole body-surface is invaded. The affection may 
be limited to one region, or several distinct regions may be involved 
simultaneously, as the head and the lower limbs, or the thorax and the 
external genitals. The hands and the feet are usually the last to be 
attacked. The eruption may appear in reddish patches of well-defined 
or of very indeterminate outline. The skin affected may be slightly or 
apparently not at all infiltrated and raised. The redness displayed in 
the regions affected with scaling may be of the brightest crimson, 
" erysipelatous/' violaceous^ or purplish shade, or with a faint sug- 
gestion of yellowness. The scales, which usually are formed in abun- 
dance, commonly are seen loosely covering the reddish integument 
upon which they rest, though they are shed also in profusion when the 
affected surface is swept lightly with the hand. They are usually 
whitish and bran-like, but may be larger ; they are as a rule larger 
and coarser upon the lower limbs than over the neck, face, and 
chest. 

In well-marked cases the features may be disfigured slightly by 
tumefaction of the lips, swelling of the ears, and puffiness of the eye- 
lids. In most cases the skin is dry, but rarely is moistened with a 
pathological discharge. 

In the course of the disorder the hairs may fall, and in some cases 
the resulting alopecia is general. When the nails also are lost there 
is rarely any special preexisting onychia. The mucous surfaces of the 
eyes, nose, mouth, and throat may participate in the general disorder 
and become the seat of inflammatory and, in rare cases, even of pseudo- 
membranous and exulcerative processes. 

Itching is usually absent ; when present and severe it is relieved 
even before complete restoration of the integrity of the skin. 

The course of the disease is similar to that of the preceding type, 
but is usually of longer duration and more frequently terminates in a 
persistent universal exfoliative dermatitis. 

The third type is similar to the preceding except that it finds its 
origin in a preceding psoriasis, eczema, pityriasis rubra pilaris, lichen 
planus, or possibly in a dermatitis medicamentosa, venenata, or trau- 
matica. There may be acute attacks which subside, leaving the 
original disorder unmodified, or the process may be continued after the 
first or after successive attacks until a generalized or universal exfolia- 
tive dermatitis results, which is clinically and histologically indistin- 
guishable from the conditions resulting from either of the two preceding 
types of the disease. 

In all forms of the disorder, and especially in the last two types, 
there may be complications due to secondary infection with pus- or 
other organisms, and to traumatism. In this way moist areas, also 
pustules, furuncles, and abscesses, may be present from time to time. 
In such cases local or generalized adenopathy may occur. 

Etiology. — The cause of the disease is not known. Often it is 
accompanied or preceded by an acute or chronic toxaemia. It is 



334 INFLAMMATIONS. 

probable that a predisposition or idiosyncrasy on the part of the patient 
is an important factor. 

Pathology. — A number of observers have reported different stages 
and degrees of an inflammatory process in the corium, with secondary 
changes, chiefly those of imperfect cornification (parakeratosis) in the 
epidermis. 

Diagnosis. — The true character of the disease frequently cannot 
be determined at the time of its onset. Other inflammatory and 
scaling conditions of the skin must be excluded by the absence of the 
features characteristic of each. In more advanced stages the history 
of the disorder, as well as the absence of the characteristic features 
of other diseases with which it might be confused, such as psoriasis, 
pityriasis rubra pilaris, and squamous eczema, will be of value in 
diagnosis. 

From pemphigus foliaceus it is distinguished by the absence of 
bullae and by the absence in most cases of grave systemic disturbance. 

The disorder may rarely closely simulate pityriasis rubra of Hebra, 
but the history of steady progression without remissions, the uni- 
versally reddened scaling epidermis without infiltration, the ultimate 
atrophy of the skin, the not infrequent ulceration and gangrene, and 
finally the serious systemic conditions — all classical features in pity- 
riasis rubra — rarely are found in such combination in dermatitis exfo- 
liativa. 

Treatment. — As at least some cases are due to a toxsemia, the 
general condition of the patient should be investigated thoroughly, and 
treatment instituted to meet indications. Arsenic is occasionally 
of value, but as a rule fails, as do other so-called specific remedies, to 
relieve the condition. Any medicament which induces profuse sweat- 
ing, such as jaborandi and pilocarpin, may give relief, and in some 
instances their use has been followed by recovery. Locally, applica- 
tions should be employed to keep the skin soft and to relieve itching 
or other sensations which may be present. For this, Hebra's ointment, 
1 part to 4 of vaselin with from 5 to 10 grains (0.30 — 0.60) of sali- 
cylic acid to the ounce (30.) of the whole, is usually grateful to the skin. 
Other simple ointments and oils with or without the addition of small 
amounts of salicylic acid, carbolic acid, ichthyol, tar, or other remedies, 
may be of value. As a rule simple, mild preparations are more 
serviceable than the stronger remedies. One of the combinations of 
lime-water, olive oil, and zinc oxide, described in the treatment of 
eczema, is occasionally of service. 

Prognosis. — In the majority of instances the patient eventually 
recovers, though convalescence often is protracted and delayed by 
frequent recurrences. A small proportion of cases progress to the 
formation of a universal or exfoliative dermatitis from which the 
patient never recovers. In grave and protracted cases the general 
health of the patient suffers and a fatal result occasionally is noted. 



DERMATITIS EXFOLIATIVA NEONATORUM. 335 

DERMATITIS EXFOLIATIVA NEONATORUM. 

(Keratolysis Neonatorum.) 

Under this title Ritter v. Rittershain ] and others have described 
an exfoliating disease of the skin in nursing infants from six days to 
five weeks old, occurring most commonly in foundling asylums. The 
disorder begins usually as a reddened, exfoliating patch, most fre- 
quently on the lower part of the face, though it may appear first on 
any part of the body, and rapidly spreads until the entire surface 
is reddened and exfoliating. The surface beneath the scales is red, 
usually dry, and often excoriated. Occasionally the surface is moist, 
and in some instances vesicles and bullae appear in areas — a fact which 
lead Richter and others to class the disease with pemphigus neonatorum. 
The angles of the mouth and the mucous outlets of the body frequently 
show fissures and are covered with crusts. Often the mucous mem- 
branes of the mouth, nose, and conjunctiva are involved. The dura- 
tion varies. In most cases there is complete involution in from seven 
to ten days with few or no constitutional symptoms. Severe cases may 
last a month or longer with disturbance of the digestion and assimila- 
tion, and production often of marasmus. Pneumonia is of frequent 
occurrence. As a result of secondary infection, furuncles and abscesses 
are common ; gangrene and sepsis may follow. When healing occurs, 
it is accomplished as a simple and gradual diminution of the erythema 
and cessation of the scaling. Recurrences are not uncommon. 

The causes of the disease are unknown. Ritter believed in its 
septic origin. Kaposi considered it an exaggeration of the normal 
exfoliation of the newborn. To the bacteria found in the lesions or in 
the blood no definite etiological relation has been established. Histo- 
logical examinations (Winternitz, Luithlen) show merely a superficial 
inflammation, often with free exudation, and excessive exfoliation of 
the epidermis. 

Treatment. — The nutrition of the child should be sustained with 
proper feeding and the warmth of the body maintained. Locally the 
surface should be kept covered with a soothing oil or soft ointment, 
and care should be taken in changing dressings not to damage the 
sensitive skin. 

Prognosis is unfavorable, as about 50 per cent, of the infants 
affected with the disease die, the outcome depending largely on the 
strength and vitality of the child. 

1 Centralzeitg. f. Kinderheilk., 1878, Bd. h\, and Vierteljahr., 1879, vi., p. 129 ; Elliott, 
Amer. Jour. Med. Sci., 1888, xcv. (with survey of literature) ; Luithlen, Archiv, 189a 
xlvii., p. 323 ; and Mracek's Handbuch, Bd. i., p. 757 (full bibliography). 



336 IN FLA MM A TIONS. 



PITYRIASIS RUBRA. 

(Gr. ir'tTvpov, bran. ) 

(Dermatitis Exfoliativa. Ger., Bothkleie; Fr., Pityriasis 

RUBRA AIGU.) 

Pityriasis rubra is a rare, chronic, and usually grave inflammatory 
cutaneous disease, involving as a rule the entire surface of the body, 
in which the skin usually without infiltration becomes deeply reddened 
and exfoliates lamella? of scales in large quantities. There is com- 
monly no subjective sensation save that of chilliness ; and the later 
symptoms and sequela? of the affection are : shedding of the hairs, 
adenopathy, pigmentation, atrophy, and, as a consequence of pressure 
and friction-effects, ulceration. The cutaneous manifestations are 
probably but symptoms of systemic disease which in the majority of 
cases terminates fatally. 

The disease here described is the pityriasis rubra of Hebra, which 
should not be confused with other forms of dermatitis exfoliativa. 

Symptoms. — This disease is characterized by a superficial hyperemia 
and inflammation of the skin, declared in patches or by a diffuse red- 
ness of a vivid or lurid tint, and by an abundance of small or large, 
lamellated, bran-like scales, which are continuously exfoliated from the 
epidermis throughout the course of the malady. Patients rarely present 
themselves for observation until a considerable portion of the body- 
surface is involved ; but Kaposi states that in two patients observed 
by him the disease was first noticed in the neighborhood of the articu- 
lations. There are never at any time other lesions of the skin, betrayed 
in vesiculation, pustulation, moisture, or crusting. The palmar and 
plantar surfaces are usually less distinctly reddened than the face and 
the extremities, having at times even a pallid hue, but they are always 
covered with a scaling epidermis. 

Under pressure with the finger the redness subsides or assumes a 
yellowish shade, while, as a rule, when the integument is gathered up 
between the finger and thumb, no infiltration can be recognized. Ex- 
ceptions, however, have been noticed by several observers. 1 The tem- 
perature of the skin is slightly increased. The exfoliation, as the dis- 
ease progresses, is one of its most striking characteristics, the scales 
accumulating in large quantities in the clothing of the patient, who is 
engaged, as a French writer has it, in the labor of stripping himself 
involuntarily of his epidermis. 

The disease persists for months or for years, being always more 
severe in expression as it advances, the papery scales being shed more 
abundantly and in larger flakes, leaving a smooth, shining, occasionally 
purplish or even cyanotic skin. In the patients observed by Jamie- 
son, 2 the skin was so dark hued as to suggest the color of a mulatto. 
Gradually the patient becomes conscious of an increasing sense of 

1 We have reported one such case. Of. " Pityriasis Kubra," Chicago Med. Jour, 
and Exam., Feb., 1881. 

2 Edinburgh Med. Jour., 1880, xxv., p. 879, 



PITYRIASIS RUBRA. 337 

chilliness, as if deprived of sufficient body-covering. The itching may 
be absent, be moderate, or be severe. There may be instead sensations 
of stiffness, burning, and tingling. Later the integument seems to 
retract, as if it were insufficient to encompass the body, and becomes 
subject to fissure from extension and contact, while the lower extremi- 
ties may be cedematous. This retraction may be so marked that ectropion 
of the eyelids may ensue, the fingers may remain semiflexed, and wide 
opening of the month may become difficult. The skin over bony 
prominences becomes thin and stretched, and often fissured, cr be- 
comes the seat of superficial ulcers or of gangrene. Thinning of the 
skin of the soles of the feet may render walking painful or impossible. 
The hairs and the nails lose their lustre and become friable, and the 
hairs often fall, though the nails may escape. 

The influence of this epidermal catarrh, involving, as it does, 
finally, every portion of the body-surface, does not fail toward the 
end to be felt by the vital forces. Alternating chills and febrile proc- 
esses, pneumonia of a low grade, colliquative diarrhoea, tuberculosis, 
subcutaneous abscesses, bedsores, and even gangrene of the skin may 
close the scene. 

Hebra and Kaposi together had under observation twenty-one 
patients affected with pityriasis rubra, who, with a single exception, 
died from its effects. It will thus be seen that the disease is rare. A 
few cases have been reported by British authors. Among Americans, 
Duhring, George H. Fox, of New York, and one of us, have published 
reports of cases. We have had under observation in all eight typical 
instances of the affection. The disease is one of early or of middle life, 
and affects preeminently the male sex. 

The progress of the disease is slow, lasting for years, though in a 
few instances the disease has proved rapidly fatal. The time required 
to extend to the entire surface of the body varies from a few days to 
two years or more, but averages from three to eight months. From 
the first the tendency of the disease is to progress slowly to a universal 
atrophy of the skin. Involution of areas, or periods of improvement 
of the cutaneous symptoms, are very unusual. There are no red points 
visible as in other forms of scarlatinoid-shaded eruption, and the color 
when the palms and soles are involved only appears after the thick epi- 
dermis of those regions has been shed. Sweat may or may not be 
secreted in the course of the disease. The tongue is bright red in the 
early stages ; later it is covered with a brownish crust ; it occasion- 
ally undergoes exfoliation. There may be a secretion from the skin 
which at times stains the linen. Rhagades may form, especially in the 
palmar and plantar regions. While in the instances of this disorder 
first described in Vienna there was no infiltration of the skin, this 
change has been observed in other typical instances, but usually not 
deeply implicating the corium. The nails may be separated, tilted up 
from the nail-folds, softened, thinned, fissured, " worm-eaten/' or other- 
wise altered. The chief systemic symptoms recorded are : languor, 
chilliness, and even severe rigors alternating with febrile temperatures 
of recurrent type, albuminuria, diarrhoea, pulmonary oedema, icterus, 
interstitial pneumonia, bronchitis, and rheumatism. 






338 INFLAMMATIONS. 

Etiology.— The causes of the disease are unknown. It is more 
common in men than in women, and in adults rather than in children. 
The cutaneous phenomena are due in each case to some constitutional 
disorder which in the early stages frequently presents no other symp- 
toms than those manifested on the skin, the patient being apparently 
in good health. Visceral troubles are recognized chiefly at a late 
period of the malady, when it would appear that the cutaneous mis- 
chief is sufficiently extensive to induce them. The wide range of these 
disorders suggests that the cutaneous disease may result from a number 
of visceral maladies. 

Pathology. — The researches of Hans Hebra l demonstrated in two 
cases that in the earlier period of the disease there is an infiltration of 
the integument moderate in degree, succeeded at a later period by 
cutaneous atrophy, in which the rete and papillae of the corium disap- 
pear. The connective-tissue elements undergo sclerosis ; and the 
glands and the follicles of the skin are destroyed. Pigmentation is 
abundant. Petrini and Jadassohn 2 reported inflammatory infiltration 
of papillary and subpapillary layers of the corium, a proliferation of 
connective-tissue cells, and secondary changes in the epidermis. 
Tschlenow states that the primary changes occur in the epidermis, 
producing secondary inflammation in the cutis which ultimately leads 
to complete atrophy of the skin. 3 

Both Hebra and Fleischmann discovered coincident pulmonary, in- 
testinal, or cerebral tuberculosis ; and Kaposi, in one post-mortem 
examination, established an atheromatous condition of the arteries. 
Myelitis was discovered in one case by Jamieson, who has been fol- 
lowed by others in the recognition of central and peripheral neurotic 
alterations. Kopytowski and Wielowieyski i describe cocci which they 
think are factors in producing the disease. 

Diagnosis. — Many cases reported as instances of pityriasis rubra 
are not really such. The misinterpreted symptoms are often those of 
an unusually extensive psoriasis or a chronic squamous eczema, which 
commonly terminates favorably in the course of proper treatment. 

Psoriasis rarely extends over the entire surface of the body, but at 
times it is thus generalized. In these exceptional forms a long history 
of the occurrence of typical psoriatic patches may usually be obtained, 
while the bleeding surface beneath the scales and the character of the 
latter will point to the true nature of the disease. Psoriasis occurs in 
healthy, pityriasis rubra in cachectic, constitutions. Extensive eryth- 
ematous or squamous eczema, apart from all other symptoms, can be 
recognized at once by the excessive distress occasioned by the erup- 
tion. The patient lies in bed nursing his or her tender limbs, back, or 
belly. In the early stages of pityriasis rubra the patient may rise, 
dress, and move about with an expression, not of pain, but of listless 
apathy. His scales are not scanty and adherent, but are abundant and 

1 Vierteljahr., 1876, Heft 4, S. 508. 

2 Archiv, 1891,' xxiii., p. 961, and 1892, xxiv., pp. 85, 271, 462 (an exhaustive 
treatment of the subject with bibliography). 

3 Archiv, 1903, lxiv., p. 21 (report of three cases with survey of the literature). 

4 Archiv, 1901, lvii., p. 33; and Jour. mal. cutan., 1901, s. vi., xiii., p. 533 (bibli- 
ography). 



PLATE VI 

Fig. 1. 




Pityriasis Rubra Pilaris. 



Fig. 2. 




Pityriasis Rubra Pilaris. 



PITYRIASIS RUBRA PILARIS. 339 

exfoliate freely. There is, from first to last, no history of moisture. 
In every generalized eczema, at one point or another, there always will 
be a surface which weeps. In its early periods pityriasis rubra can be 
distinguished from pemphigus foliaceus by the absence of bullae and 
of the intolerable stench which is often emitted by the sufferer. When, 
however, there is present merely a generalized exfoliative dermatitis the 
two disorders may well-nigh be indistinguishable. 

Treatment. — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the exhibi- 
tion of this drug in prodigious quantities for long periods of time. Tar 
externally promises no better result. Kaposi reports a single patient 
relieved by the use internally of carbolic acid. Thyroid extract may 
be tried in chronic cases. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinine, is generally indicated, with externally the simplest 
bland unguents, such as vaselin, lanolin, or diachylon ointment. They 
should be employed, not merely to soothe, but also to protect the skin. 
Continuous baths may be of service in making the patient com- 
fortable. ' The clothing should be ample and unirritating, and the diet 
selected with a view to supporting the strength. 

Prognosis. — Nearly all the cases have terminated fatally. 



PITYRIASIS RUBRA PILARIS. 

(Lichen Ruber Acuminatus [Kaposi]. Fr., Pityriasis rubra 

PILAIRE.) 

Pityriasis rubra pilaris is a chronic, mildly inflammatory, exfoliat- 
ing disease of the skin in which the characteristic lesions are fine, 
acuminate, firm papules situated at the mouths of the hair-follicles 
and displaying at the apex a horny plug or scale which dips into 
the follicle. By coalescence the papules form reddened, scaling areas 
which may spread and cover the entire surface of the body. This 
affection has been described chiefly in France by Devergie, Besnier, 1 
Richaud, Brocq, and others. The museum of the St.-Louis Hos- 
pital is provided with illustrations in wax of every phase of the malady. 
Cases of the disease in considerable number have come under the ob- 
servation of experts in America in the past few years. The malady 
is undoubtedly identical with the lichen ruber acuminatus of Kaposi. 2 

Symptoms. — The disease usually begins insidiously, but may appear 
more or less suddenly with or without mild systemic disturbance. As 
a rule the characteristic papules are not seen until after a period in 
which the disease appears as a seborrhcea sicca of the scalp with or 
without palmar and plantar scaling patches. The disorder may ap- 
pear first on the face as fine pityriasis or as a condition simulating 
seborrhcea sicca about the nose and cheeks. A similar fine desquam- 

1 Annates, 1889, s. ii.,'x., pp. 253, 398, 485. 

2 The relationship existing between Pityriasis Kubra Pilaris, Lichen Euber Acum- 
inatus (Kaposi), and Lichen Ruber (Hebra) is considered in a paragraph under the 
last-named title. 



340 



INFLAMMA TIONS. 



ation may be present on the neck and other parts of the body 
before the appearance of papules, but as a rule the latter appear on 
one or more regions soon after the first evidence of the disorder and 
gradually extend to other portions of the body. The disease is usu- 
ally most, marked over the extremities and on the back of the neck, 
but may involve any or all portions of the body. Occasionally, in the 
acute type of the disorder, a large number of isolated papules appear 
somewhat suddenly over several regions, producing a condition simu- 
lating goose-flesh. 

The characteristic papules are minute, acuminate, hard, dry, and 
of a color varying from that of normal skin to the different shades 
of pink, rosy yellow, or duller hues. The papules are situated at the 
hair-follicles and each is pierced by a hair. At the apex of the papule, 
surrounding the hair, is a horny sheath which penetrates the hair- 
follicle for a short distance. Fine lanugo-hairs which penetrate the 
papules may be recognized only on close inspection, the whitish 
horny plugs then giving the papules a scale-capped appearance. 

The papules become more and more numerous, and appear at times 
to coalesce, and may form a patch covered with fine elevations — 
conical and discrete ; or may become rounder and flatter and coalesce 
so completely as to be lost in the general scaling, exfoliating, ery- 
thematous, and shining area. The yellowish-red or deep-reddish 
patches may be the seat of pityriasic scaling, or may exhibit separation 
of the epidermis in large, adherent flakes, which especially over the 
elbows and the knees present the appearance of psoriasis. When the 
infiltration is moderate, the intensifying of the natural lines of the skin 
is a conspicuous feature. The areas are irregular in size and shape, 
but frequently have an angular or oblong outline. Commonly at the 
borders of these patches are found the initial papules of the affection, 
still isolated and surrounding characteristic stumps, filaments, or black 
points of hairs, enabling one thus to make the diagnosis with ease. 

When discrete papules are grouped closely, and in areas formed 
by aggregation rather than by complete coalescence of the papules, a 
" nutmeg-grater " effect is produced when the finger is passed over them. 
At times the eruption is generalized ; when the face chiefly is involved 
the slight crusts formed are decidedly of the type of those described 
under Eczema Seborrhoi'cum. In many cases the tension of the dry, 
infiltrated skin produces ectropion of the lower lid. Occurring over 
the hairy scalp, the accumulated scales and crusts may form a dense 
and resisting cap which is difficult to remove. The nails are usually 
grayish, yellowish, longitudinally striated, and roughened. There 
may also be a coincident polytrichia. Important for purposes of 
diagnosis are the little horny, blackish, conical papillae occupying the 
site of the hair-follicles on the dorsal surfaces of the first and second 
phalanges of the fingers. These usually remain distinct even when on 
all other parts of the body the identity of the papules has been lost in 
the general exfoliative process. 

The course of the disease is usually chronic, irregular, and subject 
to relapses and to unexpected exacerbations. The disease has a ten- 
dency to become generalized, or even universal, and to persist indefi- 



PITYRIASIS RUBRA PILARIS. 341 

nitely. Periods of remission or of complete clearing of the skin are 
noted in a few instances, but the disorder usually returns. Of the 
score or more cases that have come under our observation, in four 
only have we seen the skin become entirely free from evidence of the 
disorder, though in most of the cases improvement was noted for 
varying periods. Of the four cases, in two, after periods of freedom 
from the disease varying from a few months to five years, the cutaneous 
symptoms recurred, but not in severe type ; in the other two the dis- 
order was acute in its onset, becoming almost universal within ten 
weeks from its first appearance. In one of these patients, who acquired 
syphilis soon after the appearance of the pityriasis, the latter disap- 
peared entirely in five months from its appearance and has not recurred 
at the end of a year ; the other was relieved completely at the end of 
nine months, but his subsequent history is unknown to us. 

Subjective sensations may be entirely absent, though there is usually 
a sense of dryness and of constriction of the skin. There may be more 
or less itching, though as a rule this is not marked. In the earlier 
stages, at least, the general health appears to be unimpaired, even when 
the disorder is generalized. Eventually, however, in many cases there 
is more or less failure of general nutrition leading in some instances to 
a fatal result. 

Etiology. — The cause of the disease is unknown. It commonly 
begins in the second decade of life, but has been observed at all ages. 
Cases are reported at the age of two and one-half years (Rasch *) and 
at three years (Heller 2 ). 

Pathology. — The histopathology has been studied by Jacquet, 
Taylor, 3 Heidingsfeld, Hartzell, Heller, 4 and others. The papule, 
which is the essential lesion of the disease, is formed by an hyper- 
keratosis of the epithelial layer of the superior portion of the hair- 
follicle. There is also some abnormal cornification of the epidermis 
not limited to the hair-follicles. The mild inflammatory process in 
the corium is probably secondary to the epithelial changes. 

A number of the German cases (under the name of lichen ruber 
acuminatus) have been studied by Hebra, Kaposi, Keumann, Biesia- 
decki, Joseph, and others. The different reports vary considerably, 
depending apparently upon the age of the lesions examined. On the 
whole, the process corresponds closely to that described above, except 
that most of the observers reported more pronounced inflammation in 
the corium, as a result of which Kaposi and others believed the epi- 
thelial changes to be secondary to an inflammation of the corium. 

Diagnosis. — The disease is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, of 
a hair. In extensive cases of long standing the identity of the papules 
may be lost in the general scaling process over most of the body ; but 
in nearly all cases they can be recognized on the backs of the fingers, 
as described above. From lichen planus the diagnosis is not difficult 

1 Centralbl., 1899, i., p. 199. 

2 Zeitschrift, 1903, x., p. 153 (with histological study), 
s N. Y. Med. Jour., January 5, 1899, p. 1. 

* Loc. cit. 



342 INFLAMMATIONS. 

in the early stages or when individual papules are found bordering the 
larger areas. The dull-crimson or violaceous hue of patches of lichen 
planus is characteristic. Moreover, the disease is rarely so generalized 
as pityriasis rubra pilaris. In psoriasis the characteristic silvery-white 
imbricated scales, the bleeding points beneath, and the larger size of 
the primary lesions will usually establish the diagnosis. In pityriasis 
rubra (of Hebra) the history of the disease, the absence of distinct 
papules and of infiltration, and the appearance later of atrophy of the 
skin are distinctive features. It must be remembered that rarely pity- 
riasis rubra pilaris terminates in a generalized exfoliative dermatitis 
which cannot be distinguished from the same process arising from 
psoriasis, eczema, or other scaling affections (see Dermatitis Exfoliativa). 

Treatment. — Systemic treatment should be varied to meet the 
indications in each individual. In many cases tonics, cod-liver oil, 
and especially a nutritious diet are indicated. Arsenic has given excel- 
lent results in some cases, but in a large number has failed, and in a 
few instances apparently has aggravated the disorder. We have had 
marked amelioration of the symptoms following the combined use of 
arsenious acid, grain ^ (0.0033), and protiodide of mercury, grain \ 
(0.01), three times a day, combined, however, with external applications. 

The local treatment corresponds closely to that of psoriasis, squamous 
eczema, and other exfoliative conditions. The daily use of an oint- 
ment containing from 5 to 20 grains (0.30-1.30) of salicylic acid to the 
ounce (30.) of vaselin, or of equal parts of vaselin, lanolin, and olive 
oil, is often of value in keeping the skin soft and relieving the itching 
when present. For markedly thickened areas, ointments containing 
salicylic acid in the strength of from 20 to 60 grains (1.30-4.) or more 
to the ounce (30.) may be used ; or some of the preparations of chrys- 
arobin, resorcin, or ichthyol recommended for the treatment of psoriasis. 
Fatty crusts, when these are abundant, are to be removed by shampoo- 
ings as in seborrhoeal affections of the scalp. 

Prognosis is unfavorable with respect to the cutaneous manifesta- 
tions, as in those cases in which the disorder disappears temporarily it 
almost invariably recurs. The tendency of the disease is to persist 
indefinitely. The general health may be unimpaired, but is affected 
sooner or later in many instances. The final outcome may be fatal. 



EPIDEMIC EXFOLIATIVE DERMATITIS. 

[Epidemic Skin-disease (Savill).] 

During the summer and autumn of 1891 an epidemic disorder with 
cutaneous symptoms developed in several London asylums, infirmaries, 
and hospitals, affecting about five hundred patients. The disease was 
studied with special care by dermatologists and medical men. The 
brief sketch given below is based upon an excellent monograph with 
colored and photographic illustrations by Savill, 1 on various communi- 
cations made on the subject in the columns of the British Medical 

1 An Epidemic of Skin-disease resembling Eczema and Pityriasis Kubra, by Thomas 
London, 1892. 



EPIDEMIC EXFOLIATIVE DERMATITIS. 343 

Journal and the London Lancet for 1892, and on the description given 
by Crocker in his treatise. 

The disease occurred in two distinct clinical types, one with catarrhal 
exudation from the skin, resembling the moist forms of eczema, the 
other dry and non-discharging, resembling pityriasis rubra, and, accord- 
ing to Crocker, indistinguishable from that disease. 

The eruptive features were apparently not preceded by prodromata, 
but gastro-intestinal disturbance (vomiting, diarrhoea), and in some 
cases sore-throat, either preceded or accompanied the appearance of the 
dermatosis. Except in patients of advanced years, there was usually 
post-occipital and cervical adenopathy, not to be explained as sympa- 
thetic with a cephalic eruption. The regions most frequently involved 
were the upper limbs, the scalp, and the face ; the lower limbs less 
frequently. 

The skin-lesions were pruritic, and were irregularly grouped, acumi- 
nate papules, with a follicular site. 

The stages of the exanthem, as given by Savill, were : 

a. A papulo-erythematous stage, lasting from three to eight days, 
in which shot-like papules w T ere felt beneath the skin, were dis- 
crete, and were seated on a reddened, thickened, even an indurated 
or cedematous integument. In some cases the onset was in the form of 
marginate and circular nodose patches, resembling those seen in 
erythema nodosum ; in a few cases the resemblance was to ringworm, 
flattened papules enlarging to a circinate annular group with minute 
central vesicles readily ruptured. 

b. An exudative stage, lasting from three to eight weeks, in which 
macules, vesicles, or papules soon formed a confluent eruption, the 
skin being of crimson hue, thickened, and scaling in flakes or in 
lamellated crusts in consequence of the exudation. In the moist type 
the papules developed to vesicles with exudation ; in the dry type the 
exfoliation occurred in pure scales, pints of which in some cases could 
be collected from a patient's skin in a day. In other cases this exfo- 
liation was in the form of an impalpable powder ; it was characteristic 
of all well-marked cases. 

c. A stage of subsidence, in which the disease proceeded to invo- 
lution, leaving the skin at first indurated, polished, and brownish 
in color. In many cases the new skin was raw and parchment-like, 
smooth, shining, and readily fissured, resembling in this respect ich- 
thyosis. In a few instances ectropion resulted, as a sequel of conjunc- 
tivitis. In severe cases the hair and all the nails were shed. There 
was a mortality of from 5 to 13 per cent., death resulting from ex- 
haustion with the usual signs of subsultus, shallow respiration, and 
coma. Complications occurred with pneumonia, gangrene, and albu- 
minuria. A few of the attendants upon the sick (children and patients 
of somewhat older years) were attacked ; but for the most part the 
patients, and especially those succumbing to the disease, were individ- 
uals of advanced years of both sexes, inmates admitted for the man- 
agement of other disorders in the institutions in which the disease 
prevailed. 

The Etiology of the disease w T as not satisfactorily determined. Cocci 



344 INF LA MM A TIONS. 

were isolated and cultivated by Savill and Russell, but the etiological 
importance of these micro-organisms is yet to be demonstrated. 
Echeverria 1 described a peculiar form of degeneration in the nuclei of 
the prickle-cells. The influence exerted upon the disease by para- 
siticides was beneficial to a degree ; but this treatment on the whole 
was unsatisfactory and chiefly amounted to amelioration of the con- 
ditions of the skin. 



PSORIASIFORM DERMATOSES. 2 

(Parapsoriasis [Brocq].) 

Under this heading may be grouped a series of forty-five or more 
cases reported since 1890 by different observers under the following 
names : Parakeratosis Variegata (Unna, Santi, Pollitzer) ; Der- 
matitis Variegata (Boeck) ; Dermatitis Psoriasiformis Nodu- 
laris (Jadassohn) ; Lichenoid Eruption (Neisser) ; Pityriasis 
Lichenoides Chronica (Juliusberg) ; Erythroderma pityri- 
asique en Plaques disseminees (Brocq) ; Lichen Yariegatus 
(Crocker). As seen by the different reporters, these cases have 
suggested certain phases of one or more of the following dis- 
orders : psoriasis, eczema seborrhoicum, pityriasis rosea, lichen 
planus, pityriasis rubra, the early stages of mycosis fungoides, and 
the maculo-papular syphiloderm. In each case reported, however, 
the observer was satisfied that the condition could not be classed 
with any one of these diseases. The cases reported all have many 
features, both clinical and pathological, in common. Fox and Mac- 
Leod 3 believe that the conditions described are related very closely, 
and suggest that they be grouped under the name " Eesistant 
Maculo-papular Scaly Erythrodermas." Brocq 4 believes the 
cases are but varieties of a single disease which he terms Parapsori- 
asis. Crocker groups them all under the title Lichen Yariegatus. 
Bucek 5 accepts Brocq's classification with some modifications. White 6 
Jadassohn, 7 Himmell, and Kreibich, 8 however, believe the group in- 
cludes at least two distinct though closely related diseases. 

In all of the cases reported there has been more or less redness and 
scaling of pinhead-sized or larger, sharply defined areas. The lesions are 
slow of evolution, indolent in type, nearly or entirely devoid of sub- 
jective sensation, very superficial, showing little or no infiltration of 

1 Brit. Jour. Derm., 1895, vii., p. 9. 

2 This term, suggested by Jadassohn, is chosen temporarily as it is concise and 
involves no suggestion of etiological or pathological relation of these dermatoses to 
other definite disorders. 

3 Brit. Jour. Derm., 1901, xiii., p. 319 ; and Jour. Cutan. Dis., 1901, xix., p. 424 
(report of a case with summary of cases previously reported). 

4 Annales, 1902, s. 4, iii., p. 433 ; and Jour, Cutan. Dis., 1903, xxi., p. 315. 

5 Monatshefte, 1903, xxxvii., p. 141 (bibliography). 

6 Jour. Cutan. Dis., 1900, xviii., p. 356; also C. J. White, Ibid., 1903, xxi., p. 153. _ 

7 Archiv, 1903, lxv., p. 47 (report of a case and review of the subject with bibli- 
ography,, by Himmel, and note by Jadassohn, discussing relationship of the different 
types reported). 

8 Wien. klin. Wchnschrft. , 1902, xv., p. 674; abstr. in Archiv, 1903, lxvi., p. 261 
(report of six cases). 



PSORIASIFORM DERMATOSES. 345 

the skin, persist for months or years, and are very resistant to local 
treatment. The color of the lesions is usually a pale red, or a yel- 
lowish or brownish red, and varies somewhat in the different types 
described. The pityriasis, wanting in a few instances, is usually a 
conspicuous feature. The lesions affect generally the trunk, neck, 
arms, and thighs, but may appear on other parts of the body. Cases 
are reported in both sexes, the ages of the patients varying from 
eight to sixty years. As a rule there is no disturbance of the gen- 
eral health. The duration of the disease varies from a few months 
to thirty years, lasting in the majority of the cases for a number of 
years. The scalp remains free, and the face, hands, and feet are 
involved rarely. 

Brocq's subdivision of the cases into three types, while not wholly 
satisfactory, is utilized here as a matter of convenience. In the first 
type, which he designates Parapsoriasis Guttata, the lesions begin 
as pin-head- to split-pea-sized macules or flattened papules, covered 
with fine scales, the color varying from brownish pink to a pinkish 
red. The lesions are defined sharply, but show no definite grouping. 
The scale may be thin and adherent, and not apparent until it is de- 
tached by gentle scraping. This type of the disorder resembles gut- 
tate psoriasis, but differs from it in distribution and grouping of the 
lesions, in less profuse scale-formation, in a lack of infiltration of the 
skin, and in the absence in most instances of bleeding points on the 
removal of the adherent scale. The lesions may bear a marked re- 
semblance to maculo-papular lesions of syphilis, but are distinguished 
by their superficial character, their less definite color, and especially by 
the history of slow evolution, persistence, and absence of evidences of 
syphilis. 

In the second division, which Brocq terms Parapsoriasis Lichen- 
oides, and which he states presents features intermediate between 
lichen planus and psoriasis, and in which he classes the cases 
described under the names of parakeratosis variegata and lichen va- 
riegatus, the lesions begin as pin-point- to pin-head-sized, bright- 
red macules or flat papules, resembling imperfect lichen planus 
papules. They may show slight central depression or have an atrophic 
appearance, and often are covered with fine adherent scales, which may 
be scraped off without causing bleeding. The lesions tend to coalesce 
to form a sinuous and irregular network in which variously sized areas 
of normal skin are enclosed. The color varies from a pale pink to a 
bluish red, depending largely upon the location. Theretiform arrange- 
ment of the lesions, together with the varying color, gives the skin a 
peculiar marbled or variegated appearance, which is characteristic. 

The third variety, which Brocq terms Parapsoriasis in Patches, and 
which bears more or less resemblance to superficial eczema seborrhoicum, 
or to faded pityriasis rosea, and which includes the cases described as 
Gryihrodermie pityriasique en plaques disseminees, occurs in sharply 
defined circumscribed patches of from half an inch to two or three 
inches in diameter. There is no definite arrangement of the patches. 
The color varies from a pale red to a brownish or livid red, and the 
areas are covered more or less with fine branny scales. As in the other 



346 



INFLAMMA TIONS. 



forms, the disease is indolent, presenting little or no infiltration of the 
skin, slight or no subjective sensations, is slow of evolution, and offers 
great resistance to local treatment. 

We have had under observation two cases of this third variety. Both 
patients were blond men, between thirty-five and forty years of age, and 
we had treated both for syphilis. In one the lesions appeared early in 
the third year of syphilis, and in size and distribution suggested a 
mild pityriasis rosea. The patches were even fainter than those of 
the latter disease and resisted local treatment, though vigorous applica- 
tions of ichthyol were followed several times by almost or complete 
disappearance of the patches. In the second case the lesions appeared 
eight years after acquiring syphilis. The patches were larger than in 
the first case, and during the six years the man has been under observa- 
tion we have never seen his skin entirely free from the disease, though 
the areas become inconspicuous at times and occasionally certain areas 
disappear entirely as new ones form. 

With the first division Brocq classifies the cases reported by Jadas- 
sohn and Juliusberg as dermatitis psoriasiformis nodularis, or pityiiasis 
lichenoides chronica. 1 Jadassohn states, however, that in these cases 
the lesions begin as minute, bright-red papules which never attain a 
size larger than a lentil ; the original papules gradually flatten and 
become of a duller color, and are covered with a horny layer which 
later becomes apparent as a scale very closely adherent at the centre 
of the lesion. On the removal of these scales the surface beneath 
shows frequently an umbilication and occasionally a tendency to 
bleed, though not so marked as in psoriasis. In none of the cases 
reported has there been any retiform arrangement of the lesions or any 
coalescence of papules to form larger areas. The inflammatory 
symptoms are more marked, and there is much more distinct parakera- 
tosis (meaning by this a thickening of the horny layer with cells which 
retain their nuclei and some moisture) than in the other types described 
by Brocq under parapsoriasis. 

Pathology. — The causes and nature of these dermatoses are not 
known. Fox and MacLeod suggest " a vasomotor disturbance asso- 
ciated with oedema, infiltration of cells in the corium, and secondary 
changes in the epidermis." Sections show the changes to be limited 
to the superficial layers of the corium and the epidermis. In the 
papillary and in some instances in the subpapillary layers there is an 
infiltration of small round cells (probably lymphocytes) about the 
dilated vessels. The cedema is a marked feature, and extends to the 
epidermis, where it is intercellular and occasionally intracellular. The 
papillae are flattened, the basal layer of epithelial cells broken up by 
the oedema so that the dividing-line between epithelium and corium is 
obscured in places. The infiltration shows no plasma- or mast-cells, 
and there is no evidence of endothelial or connective-tissue-cell pro- 
liferation. In most instances the rete is thinner than normal, though 
it may be thickened more or less. The stratum lucidum is absent. 
In some of the cases, notwithstanding the fact that the stratum granu- 



1 The cases reported recently by Himmel and Kreibich belong to this class. 



LICHEN RUBER. 347 

losum is usually wanting, or cedematous, but few nuclei are visible in 
the horny layer. 

Treatment. — The lesions, though superficial and often indistinct, 
have proved very resistant to local treatment usually effective in 
psoriasis, eczema seborrhoicum, and other scaling disorders. The best 
results have been obtained with strong preparations of pyrogallic acid. 
Strong bichloride ointments and lotions have been of benefit in a 
few instances. 

LICHEN RUBER. 

(Gr. 1slxv v , moss.) 

(Lichen Ruber Acuminatus. Ger., Rothe Schwindflechte.) 

Under the term lichen ruber, Hebra was first to describe a disease 
which corresponds closely to the disorder described in these pages as 
pityriasis rubra pilaris. All of Hebra' s cases, however, were associated 
with grave systemic conditions and terminated fatally. Kaposi later de- 
scribed a lichen ruber acuminatus which he states is identical with the 
lichen ruber of Hebra, though in his cases the general health of the patient 
is not so seriously affected. The exact relationship existing between the 
cases described under these three titles has been the subject of much 
discussion, but as a result of the last two International Dermatological 
Congresses, where the same case was claimed as typical lichen ruber 
acuminatus by Kaposi and other Germans and as typical pityriasis 
rubra pilaris by different French authorities, and as a result of critical 
comparisons of the literature and published plates, there can be little 
doubt that pityriasis rubra pilaris and lichen ruber acuminatus (Kaposi) 
are one and the same disease. Hebra' s lichen ruber, judging from 
Kaposi's statements and from two plates (to which Crocker calls atten- 
tion), published by Hebra, was probably a severe form of the same 
disease. 

A few German authorities still teach that pityriasis rubra pilaris is 
wholly distinct from lichen ruber, which they subdivide into lichen 
ruber acuminatus and lichen ruber planus. Instances are cited by 
Kaposi, Neumann, and others, in which the acuminate and the plane 
papules coexisted in the same individual. These few cases are probably 
coincidences or modifications of usual types, and lichen planus is held 
generally to be a disease entirely independent of lichen ruber. 1 

1 Literature bearing on the subject : Discussion in Trans. Internat. Cong, of Derm, 
and Syph., Paris, 1889; Besnier, Annales, 1889, s. 2, x., p. 322 (monograph, with col- 
ored illustrations and full discussion of entire question) ; Kaposi, Archiv, 1889, xxi., 
p. 743, and 1895, xxxi., p. 1 ; Kobinson, Jour. Cutan. Dis., 1889, vii., p. 41 (with colored 
illustrations) ; Taylor (K. W.), K Y. Med. Jour., January 5, 1889, p. 1 (with histology) ; 
Neisser, Yerh. d. deutschen Derm. Gesell., IV. Cong., p. 495 (with discussion) ; Hans 
v. Hebra, Brit. Jour. Derm., 1890, ii., p. 65; Neumann, Archiv, 1892, xxiv., p. 3; 
Verh. d. Berlin. Derm. Gesell., 1901-2, p. 118; and discussion before N. Y. Derm. Soc, 
Jour. Cutan. Dis., 1902, xx., p. 572. 



348 



INFLA MM A TIONS. 



LICHEN PLANUS. 

(Gr. ?ieixv v , moss; Lat. planus, flat.) 

(Lichen Euber Planus.) 

Lichen planus is an inflammatory dermatosis, in which are dis- 
played multiple, small, flat-topped, angular or polygonal papules, often 
exhibiting a color containing various shades of crimson or purple, the 
plane apex of each being usually flat or depressed and covered with a 
horny film. This disease was described first by Erasmus Wilson in 
1869, and although in typical development its distinctive features are 
pronounced, much discussion has existed regarding its relation to lichen 
ruber acuminatus (Kaposi). Under the latter title the reader will find 
a paragraph devoted to this discussion. The disorder is of frequent 
occurrence, though it is not one of the common diseases of the skin. It 
is usually chronic, but may be acute, and although in most instances 
limited in distribution it may be extensive or generalized. 

Symptoms. ^In a typical case of lichen planus the primary lesions 
are pin-point- to pin-head-sized angular or polygonal flat papules. These 
are sharply defined, and covered not with a scale, but with a thin, 
translucent, horny film, which gives the lesions a varnished appearance. 
As the papules increase in size they retain their angular or polygonal out- 
line and remain flat, or may become slightly umbilicated. The color 
of the recent lesions is a bright crimson, that of the older a dull 
crimson or reddish purple. The greatest diameter attained by any 
individual papule is about one-half that of a small split-pea, but by 
coalescence the original lesions may form larger areas which are also 
angular, linear, or polygonal in outline, and are defined sharply from 
the surrounding skin. On the patches the thin horny covering may 
partially be broken up into very fine, closely adherent scales. The 
surface may show fine white striae. The favorite sites of the disease 
are the flexor surfaces of the wrist and forearm, and the legs imme- 
diately above the ankles, though any part of the body may be involved. 
Itching is usually moderate, but may be intense, and is rarely absent. 

The elementary lesion of every classically developed eruption is 
a flat-topped or slightly umbilicated, angular or polygonal, slightly 
elevated, sharply outlined papule, which, when studied in different 
positions so that the light falls aslant upon the surface, exhibits 
a characteristic glistening or shining top of each papule shown in 
no other eruption. On the surface of larger papules may be seen, 
on close inspection, minute whitish points and lines to which Wickham 
first called attention. The papules exhibit a peculiar crimson or pur- 
plish shade, and when the eruption is plentiful this color is so charac- 
teristic that by it alone in a well-marked case the eruption may be 
recognized by the eye before individual lesions can be identified. The 
papules vary in size from that of the head of a small pin to one-half 
that of a split-pea, Karely they may be larger, or round instead of 
angular, or an occasional papule may enlarge peripherally to form a 
circle half an inch or more in diameter with depressed centre. 

As the lesions grow older they almost invariably distinctly deepen 



LICHEN PLANUS. 349 

in shade, from a light-crimson to a dull-purplish hue, and still later to 
even a darker color. Involution of the papules often leaves a pig- 
mentation of a smoky, sepia, or even blackish hue, which is naturally 
most conspicuous and most persistent on the lower extremities. Occa- 
sionally white, atrophic-looking spots are left, which ultimately dis- 
appear. 

The lesions may be discrete and isolated, or irregularly grouped, 
but when numerous they tend by multiplication and aggregation to 
form irregular linear, angular or polygonal patches with sharp out- 
lines. Circular or circinate patches may occur. Rarely combinations 
of lines and circinate groups form exceedingly odd-lookiug figures, 
parellel lines, cockades, scaling crests, rings, rosettes, etc. The shape 
of the patch may be determined by an external irritation, such as a 
scratch-mark. 

When the papules coalesce and lose their identity, a crimson-hued 
sheet or mask of the skin is seen, generally characterized not merely by 
the color of the lichen-papules, but also by a silvery sheen, due to thin 
shining scales which do not completely cover, but which supplement, 
as it were, the empurpled patches, beside and over which they form. 
These scales are not freely shed from the surface, but are attached 
firmly. When there are decided sheets of infiltration they are most 
conspicuous over the flanks and belly, but they may also be seen 
elsewhere, as, for example, over the extremities. When the patches 
undergo involution, the scaling ceases, the infiltration subsides, and the 
intensely deep pigmentation left is characteristic of the disease, being 
often of a smoky, and even of a blackish hue. Later a slight atrophy 
may appear for a time, but permanent scarring is seen rarely if ever. 
After the disease has existed for a long time, a single band-like plaque 
of the disease may lose almost all papular features, and come to re- 
semble a deep-purplish keloid-like elevation or flat tumor imbedded in 
the skin ; or more commonly the majority of the papules are lost in 
the formation of flat-topped, brownish-red pea- to bean-sized or larger 
elevations commingled with sepia-brown pigmented spots (lichee 
planus hypertrophpous). Such nodes, ridges, or patches may be 
elevated one-fourth of an inch or more above the level of the skin, 
and may be covered with adherent horny scales or with pointed horny 
projections which give the lesions a warty appearance (lichen planus 
verrucosus). The hypertrophic forms in moderate development may 
be seen occasionally about the genitals as a result of long-continued in- 
filtration and traumatism from scratching. 

The disease, though usually limited to a few regions, is symmetrical 
as a rule, but may appear on one side only of the body. The eruption 
may cover large areas, and in rare instances the entire surface of the 
body. The favorite sites are the flexor surface of the wrist and fore- 
arm, and the leg below the knee. The disease may appear on any part 
of the body, but is seen rarely on the face or scalp, and is unusual on 
the palms and soles. 1 The nails may be involved and present lesions 
similar to those seen in psoriasis and eczema. 

When the mucous surface is affected, the disease develops in whitish 
1 Cf. Dubreuilh and Le Strat, Annates, 1902, s. 3, iii., p. 209. 



~— 



350 



INFLAMMA TIONS. 



macules, or striae, or flat papules, the latter aggregated on both sides 
of the tongue, the strise running along the line of the jaws where the 
molar teeth come in contact. The affection in this region has unques- 
tionably often been confounded with leukoplasia (so-called " ichthyosis 
linguae"), elsewhere described. In the mouth the papules of lichen 
planus are in rare instances conical at the apex. Cases are reported in 
which the disease appeared first on the mucous membrane of the tongue 
or cheeks. 1 On the glans penis the lesions are white if covered by 
the prepuce; if not covered, they are of the usual color of lichen 
planus papules. Lesions occur about the external genitals in women 
and occasionally within the vulva. 

The greatest variation is experienced in the way of subjective sensa- 
tions. In some patients the eruption, is tolerated with but few symp- 
toms of annoyance. In other patients the greatest possible distress is 
occasioned, and no subjects of scabies or of eczema suffer more. The 
eruption of lichen planus, however, is scratched less often than that of 
other cutaneous exanthemata accompanied by severe pruritus. 

The course of the disease is chronic, and when untreated it may 
last for months or years, either through persistence of the original 
papules and areas, or what is more frequent by the successive appear- 
ance of new lesions. Occasionally the disease disappears spontaneously, 
but its tendency is to persist. The disease may recur, but recurrence 
is an exception to the rule. 

Karely lichen planus may begin as an acute exanthem, becoming 
generalized in a few days, or even within twenty-four hours. In such 
cases the lesions are usually minute, of bright color, and exhibit no 
tendency to definite grouping. These acute cases may arise in indi- 
viduals previously free from all evidence of lichen planus, but more 
commonly in those who have had for months or years one or more 
chronic areas of the disease, and may run an acute course of a few 
weeks yielding readily to treatment, or may persist as a generalized or 
local chronic form. 

The general health is not involved as a rule, except when the itch- 
ing is so severe as to interfere with the patient's sleep and rest. In 
cases which are acute in origin there maybe mild systemic disturbance. 
Crocker refers to generalized cases in which the health was affected 
profoundly, a few of which terminated fatally. In this country one 
such case has been reported by Fordyce, 2 but it is not clear that the 
severe systemic disorders present in these cases have had any direct 
relation to the lichen planus. 

A number of variations from the usual clinical types occur. 3 On 
the legs and forearms, and occasionally on other parts of the body, 
rounded or oval, flat or slightly convex papules may develop to the 
size of a pea or bean (lichen planus obtusus). Kaposi, Gunsett, 4 and 
others report cases under the name of lichen ruber moniliformis in which 

1 Cf. Thibierge, Annales, 1885, s. 2, vi., p. 65 (with summary of previous records) ; 
and editorial by one of us (Hyde), Jour. Cutan. Dis., 1903, xxi., p. 105. 

2 Trans. Amer. Derm. Assoc., 1898. 

3 Cf. Crocker, Brit. Jour. Derm., 1900, xii., p. 421 (with discussion before the London 
Dermatological Society). 

4 Archiv, 1902, lx., p. 179 (with histological report and bibliography). 



LICHEN PLANUS. 351 

numerous node-like masses are arranged in lines and bands resembling 
a necklace of beads, with flattish, punctiform papules, and macules of a 
sepia-brown hue between the nodes. 

The tendency of lichen planus papules to form linear groups, or 
bands may be exaggerated to produce the type known as lichen planus 
linearis. 1 In such cases a narrow fillet of typical lesions may extend 
from the heel to the trunk along the line of the sciatic or other nerve, 
or, more frequently, from the buttock to a few inches below the knee. 
Such a case recently came under our observation. A similar arrange- 
ment of lesions may occur along the course of the nerves of the upper 
extremity or on the trunk. Again, the bands may be absolutely 
straight and apparently independent of the course of any nerve. Gallo- 
way has reported a striking example of this type, 2 and we have had 
a similar case, but less extensive, on the outer surface of the thigh 
and leg. 

Rarely some papules enlarge peripherally while undergoing invo- 
lution in the centre, and thus form circular bands and rings from 
one-fourth of an inch to an inch or more in diameter (Lichen 
Planus Annularis). These rings may be few in number or numer- 
ous, and may run into each other to form polvcyclic outlines. 3 These 
round lesions are accompanied usually by a larger number of typical 
lichen planus papules. 

Vesicles at the summit of some of the papules, and bullae occur 
in a number of cases of lichen planus, most frequently in patients 
who had been taking arsenic, but also in others who had taken no 
arsenic prior to the appearance of the moist lesions. Whitfield, 4 in 
presenting a patient, analyzed seventeen previously reported cases, in 
nine of which the patient had taken no arsenic prior to the appearance 
of bullae. He states that the presence of bullae apparently has no 
bearing on the severity or prognosis of the disease. 

Cases have been described by Hallopeau, Zarubin, 5 and others in 
which ordinary lichen planus papules coalesced and extended to form 
patches having raised violaceous borders with central atrophic areas 
(Lichen planus atrophicus). In some instances the papules were white 
from the beginning with minute telangiectases between them. Other 
patches suggested small areas of morphoea. Under the title Lichen 
Planus Erythematosus, Crocker describes two cases in which the 
papules were of a deep-crimson tint, soft to the touch, and obliterated 
temporarily by pressure. There was in both a marked telangiectasis 
of the face. Crocker mentions a similar case reported by Stirling. 

1 Of. Heller, Archiv, 1898, xlii., p. 59 (with references to previously published cases 
of this tvpe). 

2 Brit Jour. Derm., 1900, xii., p. 206. 

3 Cf. Crocker, Diseases of the Skin, p. 432 ; Engman, Jour. Cutan. Dis., 1901, xix., 
p. 209 (report of a case with histology) ; Whitfield, Brit. Jour. Derm., 1903, xv., p. 
294 ; _a.nd C. J. White, Jour. Cutan. Dis., 1903, xxi., pp. 188 and 290 (presentation of 
case with histological report) ; also Ibid., 1904, xxii., p. 38. 

4 Brit. Jour. Derm., 1902, xiv., p. 161 ; see also Allen, Jour. Cutan. Dis., 1902, 
xx., 260 (report of two cases with reference to others previously recorded and discussion 
before Amer. Derm. Assoc). 

5 Archiv, 1901, lviii., p. 323 (with histopathology and review of similar cases pre- 
viously published). 



352 INFLAMMATIONS. 

Etiology. — The causes of lichen planus are obscure. It is often 
difficult to recognize the sources of the disease, but in many cases 
a history of nervous exhaustion can be obtained. Grief, long-con- 
tinued anxiety, and overwork, especially when accompanied by great 
mental strain, frequently precede this disorder. Many patients are 
well nourished and not lacking in flesh. In fact, the combination of a 
fair degree of nutrition of the body with nervous exhaustion is to be 
recognized frequently in patients affected with lichen planus. 

Other causes cited are : traumatism (dog-bite, Walters), digestive 
disturbances, malaria, malnutrition, and diseases of the generative 
organs. Lichen planus is most common after the second decade of life, 
and is rare in children. Different opinions are entertained respecting 
the frequency with which men and women are attacked. General 
experience points to the conclusions formulated by Crocker, who 
reports more cases among (English) women than among men, while 
the statistics of the Vienna school reverse the figures. The disease is 
encountered more frequently in private practice among the nervously 
taxed of the well-to-do classes than among out-patients of public 
charities, who suffer to a greater extent than others from cachexia and 
malnutrition. Russell lately reported a case in which the disease 
followed amputation of four fingers of the right hand. 

The fact that lesions develop along scratch-lines in predisposed 
individuals leads Jacquet to state that lichen planus is always trau- 
matic, and found in individuals with a diminished vasomotor tonus, 
resulting from some disturbance of the nervous centres. Hallopeau 
and Jomier, 1 on the other hand, bring forward as evidence of the para- 
sitic origin of the disease a case in which lichen planus lesions devel- 
oped along scratch-marks in an individual who had never had the 
disease. A similar case is reported by West 2 in which the scratch- 
marks were produced by a cat. 

Pathology. — Robinson first clearly showed the pathological dis- 
tinction between lichen ruber and lichen planus. His observations 
have been confirmed by those of Boeck, Kaposi, Touton, Weyl, and 
others. Among reporters on the histopathology of the disease may be 
mentioned Crocker, Torok, 3 Joseph, 4 and Pinkus. 5 

The genesis of the disease, though not understood, is probably 
neuropathic. Colcott Fox suggests a neuroparalytic hyperemia as 
the first stage of the process. The corium shows dilatation of the 
vessels, oedema, and cell-infiltration which is limited to the papilla? and 
to the subpapillary layer, where it is defined sharply from normal 
tissue beneath. This sharp definition is characteristic of the process. 
The papillae usually are enlarged. The cells are reported by some 
observers to be leucocytes ; by others as of connective-tissue origin. 
It is probable that in the early stages and in acute stages leucocytes 
predominate. In some instances polymorphonuclears are conspicuous, 

i Annales, 1903, s. 4, iv., p. 352. 

2 Brit. Jour. Derm., 1897, ix., p. 162. 

3 Jour. Mai. cutan., 1889, s. 6, i., p. 162 (with bibliography). 

4 Archiv, 1897, xxxviii., p. 3. 

5 Ibid., 1902, lx., p. 163 (3 plates and references to literature). 



LICHEN PLANUS. 353 

while new connective-tissue cells will be found in lesions of longer 
duration. 

The epidermal changes also vary considerably according to the 
stage and acuity of the process. In acute cases with much infiltration 
of the corium the rete may be thinner than normal as a result of 
pressure. There is often, however, early in the process more or less 
hyperplasia and intercellular oedema of the rete. Unna states that 
the epithelium shows first a hyperplasia of the prickle-cells Avith inter- 
cellular oedema, increase in the granular layer, and hyperkeratosis of 
the horny layer. As the papule enlarges the centre shows an atrophic 
thinning of the rete and a more compact horny layer which, resting 
upon the flattened rete, gives the papule its umbilicated appearance. 
The density of the horny layer covering the papule gives the latter its 
glazed appearance and explains the lack of exfoliation in scales. 

The process frequently begins about the ducts of the coil-glands, 
though the glands themselves rarely are involved. The hair-follicles 
and sebaceous glands also escape. 

Crocker states that the greatest thickening of the horny layer occurs 
at the centre of the papule at the opening of the sweat-duct into 
which the horny mass projects, and that the desquamation of this plug 
leaves a depression or umbilication of the papule. 

Joseph, 1 Whitfield, and others have reported the formation of small 
vesicle-like cavities in the basal layer. Joseph explains the umbilica- 
tion of the papule by absorption of these pseudo-vesicles. 

Diagnosis. — The diagnosis rests upon the characteristic features 
heretofore described. Thus, in its size, apex, color, and course the 
papule of papular eczema is quite different from that described 
above, being brighter, redder, more acuminate at the apex, and much 
more often followed or accompanied by catarrhal symptoms. In psori- 
asis punctata the scales are abundant and readily removed ; the indi- 
vidual lesions are increased rapidly by peripheral extension, far beyond 
the fullest development of the papule of lichen. The papular syphilo- 
derm is not, as a rule, pruritic, not flattened when minute, not poly- 
gonal in shape, and not covered with a closely adherent horny scale, 
and it always occurs in patients in whom careful investigation dis- 
closes other symptoms of the disease (mucous patches, adenopathy, 
etc.). Crocker 2 calls attention to a subsiding stage of miliaria rubra 
in children which has been mistaken for lichen planus. The history 
and course of the disease will determine the diagnosis. 

The distinctions noted above in connection with lichenification of 
patches of chronic inflammation of the skin are not to be disregarded. 

Treatment. — Systemic treatment depends upon the condition of 
the patient. As many of the subjects of lichen planus are neurotic, 
neurasthenic, or suffering from other depressing or debilitating con- 
ditions, it follows that in many instances it is necessary carefully to 
regulate the diet, habits of rest, sleep, and exercise, and to administer 
tonics, cod-liver oil, and other remedies which will build up the gen- 
eral health. In some instances a change of climate, scene, and occupa- 
tion is of the greatest value. 

1 Archiv, 1897, xxxviii., p. 3. 2 Diseases of the Skin, p. 1104, 

23 



354 INFLAMMATIONS. 

Arsenic, though sometimes causing an aggravation of the symp- 
toms in acute cases, is a valuable remedy in many subacute or chronic 
and extensive cases of the disease. It maybe given as directed for the 
treatment of psoriasis. Mercury in the form of the biniodicle, bi- 
chloride, or the protiodide, is unquestionably of value in some cases. 
The protiodide, grain ^ (0.01), with or without arsenious acid, grain 
•^q- (0.0033), may be given three times a day. Crocker recommends 
the use of salicin in 15-grain (1.0) doses three times a day. Tilbury 
Fox and Robinson found the alkaline diuretics taken well diluted after 
meals of value, especially in the generalized hypersemic cases. For 
very acute cases, Crocker recommends large closes of quinine in an 
effervescent mixture. We have found the remedy of value at times 
in relieving excessive itching. Antipyrin in 5-grain (0.3) doses may 
be used for the same purpose. 

Local treatment should be directed toward the protection of the 
skin and the relief of itching. For many cases the use of a paste 
and dusting-powder as described in the treatment of eczema and 
psoriasis gives satisfactory results. A paste containing equal parts 
of lanolin, vaselin, zinc oxide, and talcum, with from 1 to 3 per cent, 
of salicylic acid, is usually effective. In very acute and extensive 
cases more relief sometimes is obtained by the use of the soothing 
lotions and dusting-powders recommended for the treatment of the 
acute stages of eczema. The same care should be taken as in eczema 
to have the clothing next the skin of soft cotton or linen. In many 
instances bathing once a day in tepid oatmeal- or bran-water, with or 
without the addition of an alkali, may precede the application of the 
paste or other remedy. Some patients, especially those with much 
scaling and infiltration of the skin, are made more comfortable with 
the use of ointments than with pastes. In subacute and chronic 
cases tar in the form of lotion, ointment, or paste, is often of value. 
Directions for its use are given in the section on eczema. For stub- 
born patches the treatment differs little from that recommended 
for inveterate psoriasis. For hypertrophic areas, salicylic acid is 
most effective. It may be applied in a paste or ointment contain- 
ing from 30 to 60 grains (2.-4.) to the ounce (30.), or better, it may 
be dissolved in equal parts of alcohol and ether, and the solution 
painted on the patch. The alcohol and ether evaporate and leave the 
acid in contact with the lesion. After a sufficient amount has been 
applied, the whole may be covered with adhesive plaster. The dressing 
should be changed every day or two, and when the part becomes 
greatly inflamed a soothing dressing should be substituted. Brocq 
and Jacquet recommend the daily use of a tepid douche for from two 
to ten minutes at a time, alternated with the application for a few 
seconds of a cold spray. 

For chronic cases with much infiltration, the arrays are indicated. 
We have used the method, in conjunction with other treatment, in six 
cases with decided improvement, including relief of itching in all, and 
unusually rapid recoveries in the three cases in which the treatment 
was carried out regularly. The number of exposures in each case varied 
from two to nine, and the technique was that recommended for psoriasis. 



LICHEN PLANUS. 355 

Prognosis. — The prognosis is in general favorable, since even cases 
of long standing usually are relieved when the subjects of the disease 
are placed under conditions favorable for recovery. When the patient 
is neurasthenic the eruptive symptoms may persist for years, accom- 
panied by intense itching and a consequent teasing of the nervous 
centres. In this class of subjects it is generally well to make a guarded 
prognosis, and to pronounce upon the future with a reserve. 

Lichen Annularis (Ringed Eruption of the Extremities) 
is a title given by Galloway 1 to a case in which several lesions having 
pale, irregular, elevated borders showing circular or circinate outlines, 
developed about the joints of the hands. The border was elevated 
one or two millimetres, about three millimetres in breadth, smooth, 
hard, and not reddened, but suggesting deep-seated infiltration of the 
cutis. The folds of the skin about the joints divided the border in 
places, giving it a nodular appearance. The lesions were slow of 
evolution and indolent in career. The skin of the enclosed area 
was almost sound, but showed slight signs of atrophy when the orig- 
inal process had undergone involution. The histological structure 
closely resembled that of lichen planus. The lesions flattened rapidly 
under the application of salicylic acid in ointment. We have had a 
similar case in a healthy boy, sixteen years of age. The lesions were 
limited to the forefinger and thumb of one hand, and entirely disap- 
peared in the course of a year under somewhat irregular treatment with 
a 50 per cent, aqueous solution of ichthyol, after salicylic acid had been 
used several months without effect. Under the title "Granuloma 
Annulare " Crocker 2 describes five similar cases and refers to several 
others reported by other observers. 

Lichenification. — This term was applied first by Brocq and 
Jacquet to areas, usually limited and circumscribed, in which the skin 
is reddened, infiltrated, and more or less covered with fine scales, but 
in which the marked feature is an intensifying of the normal lines and 
furrows of the skin, as a result of which the patch is broken into small, 
more or less elevated, triangles, squares, or quadrilaterals which closely 
resemble the flat, angular papules of lichen planus. This condition 
of lichenification is seen in the subsiding stages of various forms of 
dermatitis, and also in areas that have been subjected to mild but long- 
continued scratching or other external irritation. The disorder is seen 
most frequently about the flexures of the joints, the fork of the thighs, 
and the back of the neck, but may appear on any part of the body, 
and is sometimes quite extensive. The condition usually disappears 
promptly under protective and antipruritic treatment, but shows a 
marked tendency to recur. 3 

1 Brit. Jour. Derm., 1899, xi., p. 221 (with clinical [colored] and histological plates, 
and abstracts of similar cases previously reported). 

2 Diseases of the Skin, p. 1082. 

3 _ For full discussion of the subject, see Brocq's chapter on " Les Lichens," La 
Pratique Dermatologique, t. iii., p. 119. 



356 



INFLAMMA TIONS. 




ECZEMA. 1 

(Gr., £/c few, to boil forth.) 

(Ger. y Eczem; Fr. y Eczema.) 

Eczema is distinctly a protean disease. It cannot, therefore, be 
defined or described satisfactorily in a single paragraph. It is not 
only protean in its clinical manifestations, but its causes are varied, 
numerous, and usually complex. In histological detail different types 
of eczema vary considerably, yet all probably result from one common 
pathological process. Clinically, though a dozen successive cases of 
eczema may present wholly different pictures, yet they all have some 
characteristics in common and the diagnosis in most cases is not diffi- 
cult. It has often been described as a catarrhal inflammation of the 
skin, but many cases of dermatitis now generally classed as eczema 
show no vesiculation or other evidence of discharge, and cannot properly 
be considered catarrhal in nature. As a rule, eczema shows at some 
time in its history more or less serous discharge, either in the form of 
vesicles or in a denuded oozing surface ; but some cases of erythematous 
and papular eczema persist as such throughout their entire course, and 
never produce an exudate upon the surface. 

A vexed and unsettled question among dermatologists is the rela- 
tion of eczema to other forms of dermatitis. The study of the exact 
pathological changes in the skin has led to the inclusion under eczema 
of conditions formerly considered distinct affections. On the other 
hand, many writers, especially in England and France, are now endeav- 
oring to exclude from eczema every dermatitis for which a definite 
cause can be found. Eczema is a dermatitis, and it is not possible to 
say for every case which title is the more appropriate. A convenient, 
arbitrary division, which is followed in these pages, classes under der- 
matitis those forms of inflammation of the skin which result from 
recognized, external causes, and which subside on the removal of the 
cause. Such definite and independent affections as dermatitis herpeti- 
formis or dermatitis repens are, of course, considered separately. 

Symptoms. — Eczema is one of the diseases of the skin of most 
frequent occurrence. In the statistics gathered by medical men it 
would seem to rank first in the order of frequency, forming from 20 to 
40 per cent, of dermatological cases reported. It is undoubtedly true 
that acne is a more, common affection than eczema, but as many subjects 
of acne never deem it necessary to submit to treatment for its relief the 
records of such cases do not figure in dermatological statistics. This 
fact being noted, eczema may be regarded as the disease of the skin for 
which most frequently the practitioner of medicine is consulted. By 
as much as inflammation is the commonest accident of other organs of 
the body, by so much is its enveloping organ subject to the same path- 
ological process. 

1 For a complete presentation of the subject, with full bibliography, the reader is 
referred to the chapters on " Eczema," by Besnier, in La Pratique Dermatologique, t. ii., 
pp. 1 to 305, and by Unna, in Mracek's Handbuch, Bd. ii., pp. 169 to 393 ; also Bullr- 
ing's Cutaneous Medicine, pt. ii., pp. 311 to 420. 



ECZEMA. 357 

The accepted signs of inflammation of any given tissue are usually 
named as increased heat, redness, pain, and swelling. These symptoms 
are present to some extent in every eczema though modified by the 
anatomical peculiarities of the organ in this case affected. The surface 
involved in typical eczema always shows some elevation of tempera- 
ture, it being slight in chronic, but more marked in acute, cases. Red- 
ness, varying in shade from the bright red of the acute to the dull red 
of the chronic forms, is also true of the eczematous skin. Pain here is 
represented by a sensation of itching which is almost invariably present 
and may vary from a slight annoyance to an almost intolerable distress. 
It is commonly intermittent or paroxysmal in character and is usually 
worse at night. In some instances, especially in acute and erythemat- 
ous types, the sensation of burning or smarting may be more marked 
than that of itching. Occasionally an eczematous skin is hypersesthetic 
and exceedingly sensitive to contact with even the blandest substances. 
The degree and character of the subjective sensations in eczema depend 
largely upon the location, type, or severity of the disease, but also to 
some extent upon the general condition or peculiarities of the indi- 
vidual. The fact that itching rather than pain accompanies inflamma- 
tory disorders of the skin is due largely to the fact that the skin is 
exposed to the air, and its increase in bulk is not opposed by contigu- 
ous parts. Inflammation of the inner skin of the body, that of the 
lining membrane of the stomach or of the intestines, is generally char- 
acterized by the occurrence of severe pain. In acute types of eczema 
there is often some oedematous swelling, together with slight infiltration 
of the skin. In chronic forms the infiltration and thickening of the 
skin are more pronounced and may be excessive. 

In addition to the symptoms of heat, redness, itching, or burning, 
and swelling or thickening of the skin, found in every case of eczema, 
the great majority of eczemas have certain characteristics in common. 
The course of the disease is capricious, not only the severity of the 
process, but often the type of lesion changing frequently and rapidly. 
This is most conspicuous in children and in others having delicate 
skins, and in those cases in which the affected areas are not protected 
from atmospheric and other external influences ; it is unusual for any 
eczema to pursue an even course. Daily variations in severity, with or 
without change or modification of type, are not uncommon. Apparent 
recovery is frequently followed by a relapse which may develop fully 
in a few hours and without apparent cause. 

Aside from some cases of erythematous and papular eczema, which 
may persist throughout without change of type, eczema is notably a 
polymorphic disease, presenting in irregular succession or in varied 
combinations: erythema, papules, vesicles, pustules, crusts, scales, fis- 
sures, excoriations, or denuded and oozing surfaces. Even in the mildest 
cases the skin is slightly infiltrated, while in some severe, chronic forms 
the thickening may be excessive and deforming, or there may be hyper- 
trophy of all the layers of the skin producing wart-like growths 
(Eczema Vekrucosum). 

The serous discharge which is present during at least a part of the 
course of most eczemas is characteristic, and stiffens articles of clothing 



358 INFLAMMATIONS. 

on which it dries. It may be imprisoned in vesicles, but more com- 
monly oozes from a denuded surface or from minute excoriated points 
which represent abortive or ruptured vesicles. 

Like all other inflammations, eczema may be acute or be chronic. 
Like all others, too, the acute may precede, and the chronic may follow, 
or the reverse may occur. The disorder, originating in subacute or 
insidious forms, may become chronic, and then, as the result of fresh 
or of more severe irritation, may develop the acutest symptoms. Fre- 
quently, as in the eczema of children, the disease may be chronic in 
respect to duration, yet most of the time present acute symptoms. As 
a rule, eczema does not undergo spontaneous recovery, but tends rather 
to remain indefinitely and to extend either by involving contiguous 
surfaces or by developing in new areas. The disease is commonly 
more or less local, appearing in one or several irregular and usually ill- 
defined areas, but may be general or even universal. It apparently 
occurs independently of all other disorders, the general health remain- 
ing unaffected even in severe forms of the disease ; or it may be but the 
external expression of constitutional disturbance. 

Clinically, several types of eczema can be recognized. These types 
require separate description. It should not be forgotten, however, that 
in the majority of cases eczema is a complex process, in which two or 
more types are seen, either in succession or simultaneously. Though 
several forms of eczema frequently coexist, it is usual for one type to 
predominate, either throughout the course of the disease or for certain 
periods. 

[A] Eczema Erythematosum.— This form of the disease is most 
common on the face, especially in individuals exposed to wind and 
weather or to direct heat, but it may appear on any part of the body, 
and is frequently seen on the palms, the soles, and in the genital regions. 
It begins usually as a diffuse, ill-defined area of redness, less frequently 
as a number of coin-sized macules or erythematous spots, which may 
coalesce or remain more or less distinct. Swelling and infiltration are 
present in varying degrees. In acute cases the oedema may be exces- 
sive, sometimes closing the eyes. In the subacute forms, which are 
the more common, there are less oedema and more infiltration and thick- 
ening of the skin. 

The sensation of itching, which is so characteristic of most forms of 
eczema, is usually excessive, though it may be largely or wholly sup- 
planted by one of heat or of burning. This is especially true when the 
process is acute in character. The color varies from a bright to a dull 
or purplish red, depending upon the severity of the disease, its location, 
and the peculiarities of the individual ; and inasmuch as the condition 
is more frequently observed in middle-aged adults with darker hue of 
integument than in early life, the color of the part is often noticed to 
be of a dull-crimson shade. At times the coloration is irregularly dis- 
tributed, producing a mottled appearance, bright at one point and dark 
at another. A yellowish tinge usually indicates that the process is 
combined with seborrhoea, producing the combination described in 
another chapter as eczema seborrhceicum. 

The erythematous surface is modified, as a rule, by more or less fine 



ECZEMA. 359 

desquamation, which begins a few days after the occurrence of the first 
erythema, and persists to the end of the disease. There is no discharge, 
unless, as frequently happens, the type changes to a moist form, but 
when the disease occurs on apposed surfaces, as in the axilla, under the 
breasts, or about the genitals, the epidermis may be destroyed by 
maceration and friction, and leave a denuded, oozing surface. The dis- 
ease may pursue an acute course, terminating in exfoliation and gradual 
resolution, or changing to the papular, vesicular, pustular, or mixed 
types. More frequently it persists and becomes chronic, both in the 
intensity of the process and in its duration. The skin then becomes 
more infiltrated and thickened, and may present voluminous firm folds, 
which are very conspicuous and often deforming. Exfoliation may be 
so prominent a symptom as to suggest for the condition the name of 
Eczema Squamosum or Exfoliativum. The area involved is fre- 
quently better defined than in other forms of eczema, and though the 
condition may remain limited to its original site for months or years, 
it has a decided tendency to extend either contiguously or by the 
formation of new areas. The intensity of the process may change 
frequently and rapidly. It is usually aggravated by exposure to 
heat, cold, or wind, or by any condition which favors congestion of 
the part. Scratching of the surface involved produces a change in 
the symptoms which the skilled eye will promptly recognize. Minute 
superficial losses of tissue are then visible here and there upon the 
surface; the more recent lesions having a reddened floor possibly hidden 
beneath a thin blood-scale, the older being surmounted by a light 
yellowish-red crust. The scratch-lines, often recognized elsewhere, are 
here less evident. 

Like all other varieties of eczema, this form is extremely liable to 
recrudescence and relapse. In advanced life traces of the disease may 
be visible for years. 

[B] Eczema Papulosum. — Under this title are classed all those forms 
which have been described as Lichen Simplex, Lichen Ecze- 
matodes, Eczema Lichenoides, etc. It is of great importance that 
there should be a distinct and general recognition of the fact that in 
exceptional cases eczema may exist from first to last as a dry infiltration 
of the integument, for there is perhaps no one of the various manifesta- 
tions of the disease that is so frequently confounded with other widely 
different affections. 

The papules are acuminate, pinhead-sized or larger, colored in 
various shades of red to a dark lurid shade, and are usually seated 
upon a reddened and thickened base. They are generally discrete, 
though often set closely together, are accompanied by an intense form 
of itching ; and of all eczematous lesions are most likely to be irritated 
by scratching. Their summits are torn, often to such an extent as to 
bleed, the blood drying in minute crusts on the apices of individual 
lesions. Existing papules may persist for weeks or may disappear 
and be replaced by others. They may completely coalesce to form 
irregular, thickened, elevated, pea-sized or larger patches, covered with 
scales. The areas involved in papular eczema are often fairly well 
defined in outline. The extent of surface affected varies, the disease 



360 



INFLA MM A TIONS. 



being in some cases largely diffused over various portions of the body, 
but usually limited to small single patches no larger than the size of 
a small coin. Such patches, covered with a single or with several 
groups of reddish papules, may continue to torment the patient for 
long periods of time, or, being at one time relieved, may recur with each 
aggravation of the malady by the exciting cause. Papular eczema is a 
dry manifestation of the disease, and is thus most frequently noticed 
upon the drier portions of the integument. These parts are the surfaces 
of the limbs, the back of the body, and, in particular, the scrotum. In 
the latter region the papules are large and often flattened. If the moist 
forms of eczema are most frequently seen in early life, it is none the 
less true that the dry forms are the most common in adult life or in 
advanced years. 

It should not be forgotten, however, that the papules here described, 
when there is free exudation beneath the surface, may exhibit pin- 
point-sized vesicular summits which may develop into minute or larger 
pustules. A patch of papular eczema, where no vesiculation nor pus- 
tulation has been observed, will, if sufficiently scratched, ooze with 
moisture, the serum escaping from the abraded surface. There are, in 
fact, few scratched eczematous surfaces which will not moisten a dry 
handkerchief applied to the part. This weeping condition attracts the 
attention of patients themselves, who complain of it in describing their 
symptoms. A species of relief from the pruritus is thus obtained ; and 
in aggravated cases patients will scratch or rub or otherwise irritate the 
diseased patches, not merely for the purpose of gratifying the intense 
desire to assuage the itching, but also to induce serous exudation for the 
sake of the relief it affords. The secretion when in contact with linen 
cloths stains and stiffens them, very much as seminal fluid leaves its 
traces upon clothing. 

Resolution of papular eczema is accomplished after the formation 
of scales, the tissues beneath the latter assuming more and more the 
appearance of healthy skin. 

[C] Eczema Vesiculosum. — This expression of the disease is char- 
acterized at an early period by the formation of minute vesicles. It 
is a matter of importance, however, to recognize the fact that the 
vesicular, like the erythematous, is but one of several manifestations 
of this singularly protean affection. Long after the appearance of the 
treatises of early English dermatologists the term " eczema " was very 
generally limited by physicians to the vesicular phases of the disease ; 
it is to the Vienna school that we are largely indebted for the recog- 
nition of the fact that these simultaneous or successive features, 
presented often in the same individual, really belong to one and the 
same malady. To limit the name eczema to-day to its vesicular variety 
alone would be to relegate the student of diseases of the skin to the 
misty uncertainties of the first half-century of dermatology. 

The clinical features of vesicular eczema are chiefly due to the 
acuity of the inflammatory process present, and to the consequent free 
exudation of serum of the blood from the vesicular plexus immediately 
below the pars papillaris of the corium. The involved surface usually 
feels at the outset hot, itchy, or unusually sensitive, and soon after 



ECZEMA. 361 

becomes more or less intensely reddened, the result of hyperemia and 
subsequent exudation which may last for one or for several hours. 
Poppy-seed- to grape-seed-sized vesicles then become visible on this 
reddened base. The lesions may be closely packed together, or be 
discrete, or may be so abundant as to coalesce, a frequent behavior of 
all vesicular lesions. Each vesicle is filled with a droplet of clear 
serum imprisoned beneath the most superficial layers of the epidermis. 
This vesicle is readily ruptured, and if this rupture does not speedily 
occur as the result of accident, the lesion bursts spontaneously, and its 
limpid contents are then poured out upon the surface of the integu- 
ment. The quantity of the fluid thus exuded is in excess of that 
originally contained in the small vesicular chamber. This excess is 
due to the fact that the elevated, macerated, and broken epidermis 
no longer presents an obstacle to the outflow of serum from the 
engorged vessels beneath. Minute and even large drops of a clear fluid 
of syrupy consistency can be seen collecting at the points where the 
solution of continuity has occurred. If with a slip of bibulous paper 
the first drop be removed, its place is visibly filled by a second. Crops 
of new vesicles succeed the first, each crop being followed by the train 
of symptoms described. The vesicles are usually short lived and often 
have disappeared before the patient is seen by the physician. In other 
instances the destruction of the epidermis by rubbing or scratching, or 
by an abundant and rapidly formed exudate, allows the escape of the 
fluid without previous vesicle-formation. The discharge dries rapidly, 
when exposed to the air, in light-yellowish crusts which are rarely 
bulky. Clothing on which the fluid dries is stained and stiffened. 
The weeping at many points of the surface affected is so prominent a 
feature of the disease that it has led several authors to describe eczema 
as invariably a catarrhal disease of the skin. There are, without 
question, forms of this disease in which the history is throughout 
entirely different from that just described, in which no evidence of 
discharge can be appreciated from first to last, and yet in which, by 
artificial measures, the so-called " catarrhal " features can readily be 
produced. 

The contour of the affected patch or patches is seldom well defined, 
the pathological portions imperceptibly shading into the sound skin. 
The color of the area thus diseased varies according to the stage of the 
process, being at one time of a vivid red, at another yellowish, and, 
when covered with crusts or scales, undergoing a corresponding change 
of hue. Infiltration of the skin occurs rapidly, so that when a portion 
of the affected integument is pinched up between the finger and thumb 
is is found to be thicker and less elastic than normal. This form of 
eczema may persist or recur in a single small area, or it may spread and 
become diffused or even generalized. It appears commonly on the 
flexor and other surfaces where the skin is thin. 

The subjective symptoms of vesicular forms of eczema are more or 
less intense itching and often burning. In very acute forms there is 
considerable soreness, the patient managing the affected part with as 
much care as if it were a fractured limb. In exceptional cases, more 
frequently observed in children, there is a sympathetic febrile disturb- 
ance of a mild grade. 



362 INFLAMMATIONS. 

As resolution approaches, all the symptoms described above gradu- 
ally decline in severity ; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen and fall, and beneath the scales which have taken the place of 
the oozing and broken epidermis a new and tender epithelial covering 
is produced. As a rule, for weeks after the process has completely 
ceased the newly formed epidermis has a slightly reddened and tender 
appearance, though complete resolution is followed by no permanent 
sequels. Instead of undergoing resolution the condition may terminate 
in eczema rubrum, in eczema squamosum, or in eczema pustulosum, 
this last form being ordinarily due to pus-infection. 

These then being the typical phases of vesicular eczema, clinically 
the picture may be quite different from that described. The types here 
given are convenient for analysis and study, however much they may 
be commingled and obscured in the inflamed integument. Like the 
erythematous, the vesicular forms of eczema may precede the others, 
and, becoming chronic, may torment the suffering patient continuously 
for long periods of time, or may yield, only to reappear at irregular 
intervals. 

[D] Eczema Pustulosum (Eczema Impetiginoides, Impetigo Eo 
zematodes). — This type may originate in one of the other forms of ec- 
zema, in consequence of the severity or acuity of the process, or be the 
result of secondary pus-infection, or pustular lesions may rapidly form 
at the onset. Usually there is first seen a crop of minute vesicles, which 
enlarge and become distended with puriform contents. These pustules 
either accidentally or spontaneously burst, and the fluid w r ith which 
they were distended dries into yellowish-green or darker colored 
friable crusts. In aggravated cases the purulent matter seems to 
form directly upon the involved surface. If the process be long 
continued, infiltration occurs, and the itching, which in all varieties of 
the disorder is a characteristic feature, is awakened as an accompany- 
ing symptom. The itching, however, is rarely of the peculiarly 
aggravated type accompanying the erythematous and papular phases. 
Pustular eczema is most frequently encountered on the head, and 
in constitutions that do not readily resist the invasion of pus-cocci. 
When existing on the scalp and the face there is most commonly 
an involvement also of the sebaceous glands, the secretion of which, 
altered by the periglandular inflammation, is added to that naturally 
produced by the exudative process. Singular shades of mixed yellow 
and green and even black, are then to be distinguished in the re- 
sulting crusts, which later desiccate and fall, leaving a reddened 
and tender new epidermis beneath. The condition is frequently seen 
on the scalp and face of infants, and is then popularly called " milk- 
crust." 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and unmingled forms of 
cutaneous disease, some of them more commonly than others. To pre- 
sent, however, a picture of eczema as it is seen clinically it must be 
understood that these several forms, useful in the analytical study of 



ECZEMA. 363 

the disease, often become, in actual observation, well-nigh inextricably 
commingled. " Observation of the natural course of an attack of 
eczema," said Hebra, " furnishes the most unassailable proof of the 
connection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms ; in another it is preceded by 
the appearance of red scaly patches or groups of papules ; or vesicles 
and papules are developed together, some of the former rapidly chang- 
ing to pustules and forming yellow gum-like crusts by the drying up 
of their contents." It is this constant interchange of features that dis- 
tinguishes most eczemas from all other inflammatory affections of the 
skin. 

The name Eczema Rubrum has been given to the red and angry 
form of the disease, which, because of the free exudation of serum 
from the surface, has also been termed Eczema Madidaxs. In 
this form the highly inflamed, intensely red and wounded integument, 
the horny layer of which has been destroyed and removed, pours 
out freely upon the surface a thick, gummy or syrupy fluid, which, if 
artificially removed, leaves behind it a swollen, angry, and still dis- 
charging skin ; or, being permitted to dry where it has formed, covers 
the surface with large flake-like crusts, which may be thin and yellow, 
or thick, dark-colored, and often blood-stained. The crusts may re- 
main but a few hours before an excessive outpouring of the fluid re- 
moves them. There are thus displayed in frequent and rapid alterna- 
tion the discharging and the crusted surface. Eczema rubrum may 
occur on any part of the body, but especially in the flexures of joints 
or where two surfaces come together; another common site is on 
the legs of elderly people or of those who stand much of the time. In 
this region it is exceedingly chronic and rebellious to treatment, and 
eventually is accompanied by a great degree of infiltration and thick- 
ening which may go on to hyperplasia and produce a condition simu- 
lating elephantiasis. 

Eczema Squamosum, or Exfoliativum, is a type of the disease 
marked by more or less redness, infiltration, and exfoliation of the 
skin. The scales are usually small, thin, whitish, and adherent. They 
may be scanty or quite abundant. Squamous eczema represents a low 
grade of inflammation, and is present as a transitory condition during 
a part of the period of resolution of all other types of t'he affection. 
It frequently persists, however, in the form of irregular, usually ill- 
defined, more or less infiltrated, dry, scaly patches. It is seen com- 
monly on the neck and face, at the border of the scalp, and on the 
limbs. 

Eczema Fissum, Eczema Rhagadiforme. — In eczema of the 
hand the movements of the fingers often produce fissures or cracks in 
the inflamed and infiltrated integument, and to those fissured forms the 
titles named above have been given. Fissures are observed wherever an 
eczematous disorder has so impaired the elasticity and extensibility of 
the skin that its necessary movements, especially about the joints, tear 
and stretch the thickened integument. It is thus seen not only on the 
hands, but also on the arms, the feet, and about the ankles, the resulting 
rhagades being, at times, the most painful of all the complications of the 



364 



INFLAMMATIONS. 



malady. It is seen frequently about the mouth and anus. Occurring 
upon the bodies and the hands of those who are compelled to come in 
contact with irritating substances, this form of the disease finds its 
severest expression. Mild, commingled forms of squamous and fis- 
sured eczema occur quite commonly on the hands and faces of persons 
whose skin is thin, tender, and poorly nourished, or exposed to wind, 
harsh soaps, hard water, chemicals, and other irritants. The condi- 
tion is popularly known as Chaps or Chapping. 

Eczema Craquele is a rare form of eczema described by French 
writers in which a reddened surface is covered with large, thin flakes, 
or scales, separated and outlined in polygonal areas by superficial cracks 
or fissures. The condition usually involves a considerable surface of 
the skin, and is accompanied by itching and burning and in most cases 
by hyperesthesia and an extreme sensitiveness to temperature-changes. 
It occurs chiefly in neurotic subjects. 

Eczema Intertrigo is a name applied to that form of intertrigo 
which, surpassing the limits of hyperemia, results in an exudative 
process. Reference is made to this possibility in describing the symp- 
toms of erythema intertrigo. In eczema intertrigo the symptoms are 
usually those of diffused redness of surfaces of the skin in close appo- 
sition, macerated by previous transudation of sweat, and weeping with 
the serum which oozes from several abraded points or patches. It 
chiefly attacks the obese of both sexes and all ages, and in advanced 
years the gouty. 

The flexor surface of the extremities, especially in the vicinity of 
the joints, as well as the inframammary regions, the interdigital surfaces 
of the feet, and the axillary and inguinal spaces, are particularly prone 
to exhibit symptoms of this disease. In all such localities the alter- 
nate tension and relaxation of the integument serve, when the limbs are 
in motion, to increase the pruritus, and, correspondingly, to aggravate 
the disease. Often a certain proportion of symmetry can 'be perceived, 
the two popliteal spaces, for example, being simultaneously affected, 
though each in a different degree. The parts most favorable for the 
complications of intertrigo are those nearest the trunk, where moisture 
and heat are greater, as the groins and the axillae, while the elbow and 
popliteal spaces are more frequently dry, exhibiting papulo-squamous 
ridges in lines at right angles to the axes of the limbs, with hypersemic 
patches on either side. 

Eczema Verrucosum, or the wart-like form of the malady, is 
occasionally observed, especially upon the lower extremities, in middle 
life or in advanced years, as the result of long-continued disease. The 
integument becomes thickened and so hypertrophied as to suggest the 
appearance of warts closely packed together in a circumscribed patch. 

Eczema Sclerosum is a form of the disease most frequently 
observed upon the palmar and plantar surfaces, a condition referred 
to in the paragraphs relating to Asteatosis. In eczema sclerosum is 
presented a densely thickened inelastic integument, suggesting the con- 
dition of tanned leather, without the occurrence of any of the other 
lesions of eczema described above. As a consequence, the power of 
perfect extension of the digits is impaired. 



ECZEMA. 365 

Tuberculous Eczema of Nurslings, so called, is a term which 
has been applied to eczematoid eruptions about the mucous orifices of 
the eyes, nose, mouth, and ears, occasioned and sustained by morbid 
conditions of, and serous discharges from, those parts (otorrhcea, rhin- 
itis, phlyctenular keratitis, etc.), and accompanied by oedema, vesicula- 
tion, and enlargement of lymphatic glands. The disease is character- 
ized by rebelliousness to treatment and chronicity of course. This 
disorder is improperly named, since tubercle-bacilli have not been rec- 
ognized in its lesions; and because the symptoms above enumerated 
may all be present when there is simply systemic nutritive failure and 
when no tuberculosis of other organs is present. 

Eczema Diabeticorum (Fr., Diabetides). — A singularly well- 
defined eczema is to be recognized about the genital organs of both 
sexes, but more particularly of women, accompanied by the most 
atrocious pruritus, excoriations produced by scratching, and enormous 
tumefaction of the anogenital and surrounding integument. The local 
symptoms are chiefly those of eczema erythematosum, the surface 
being, as a rule, destitute of either vesicles or pustules. There are 
often a profuse serous discharge, considerable infiltration, and the pro- 
duction of inflammatory nodules over the engorged surface. 

These cases fall within three categories. In the first and rarest the 
patient has saccharine diabetes of long standing, and the parts are 
simply irritated by the passage over them of urine charged with sugar. 
In the second and commoner form there is a temporary glycosuria, 
either produced by the local eczema or indirectly resulting from the 
latter, and yet due to transitory causes, since both the eczema and 
saccharine urine disappear with relative rapidity when the local treat- 
ment is combined with the dietary appropriate for the diabetic. In a 
last group the sugar-fungus (Torula cerevisice) finds a nidus in the skin. 

Eczema Folliculorum. — Morris first described under this title 
a form of eczema which begins as an inflammation of hair-follicles. 
Each inflamed follicle projects from the surface in the form of a red- 
dened papule about which the skin becomes hyperaemic. As the 
process spreads centrifugally by the involvement of adjacent follicles, 
the centre undergoes involution with desquamation, and a gradual 
change in color from red to yellow. This condition is found most fre- 
quently on the extensor surfaces of the legs and the arms, in multiple, 
scattered patches. The itching may be intense. This form of eczema 
is obstinate, and usually recurs. Morris considers it parasitic in origin 
and allied to sycosis. 

Eczema Parasiticum. — Under this title is included a large num- 
ber of cases the exact relations of which to the recognized types of the 
disease are still indeterminate. It is well known, for example, that the 
surface of the human body in health is the habitat of an enormous 
number of different parasites which are, for the most part, harmless or 
are effective as agents of disease only under certain specially favorable 
conditions of the body. Cultivation-experiments with the flora found 
on the eczematous skin have revealed a large number of parasites which 
together, if not singly, may be effective in producing some of its dis- 
tinctive features. According to Unna, eczema is in these cases a 
chronic parasitic catarrh. 



366 INFLAMMATIONS. 

Eczema Marginatum is considered under the head of ringworm. 
Eczema Seborrhceicum is described separately under that title. 

Acute Eczema. — An acute attack of eczema may be ushered in by 
malaise, chilliness, or the recognized symptoms of the febrile state. With 
or without these prodromata the affected portion of the skin-surface 
becomes the seat of a burning sensation which is soon succeeded by 
redness and swelling. This tumefaction may occur upon one or upon 
several portions of the body at the same moment of time, and the dis- 
ease throughout be limited to a single area or to several spaces ; or it 
may extend from one to other or all regions. This extension may pro- 
ceed by continuous development of the disease along the surface, or an 
eczema of the thigh may suddenly be followed by an eczema of the 
face, and this by an eczema of the scrotum. Extension of eczema by 
the last-described course may occur when no constitutional cause can 
be discovered and undoubtedly is due largely to the extraordinary 
sensitiveness of the skin when involved in an acute attack, in con- 
sequence of which the slightest friction, or even reflex irritation of 
the blood-vessels produces a new focus of the disease at a distant point. 
This consideration is of special importance. Patients will frequently 
point to an acute eczema upon several portions of the body widely 
separated one from another, and will urge this as an irrefutable argu- 
ment in favor of the fact that they suffer from some " poison in the 
blood." 

The tumid and erythematous surface above described soon assumes 
the features of one or more of the types of eczema outlined in the 
preceding pages. In this manner the evolution of the disease occurs, 
and may continue for weeks, the patient, if unrelieved, being tormented 
by the itching, and, if the disease be extensive, being prevented from 
attending to his usual vocation. Acute eczema of severe grade will 
frequently prostrate a strong adult, confining him to his bed-chamber 
and often to his bed. When there is a simultaneous febrile process the 
emaciation and adynamia are proportioned to its severity. Weeks and 
even months may elapse before recovery can be pronounced complete, 
subacute patches of the disease lingering here and there upon the sur- 
face, crust-hidden, scale-covered, occasionally oozing from recrudescence 
of symptoms. Recovery, even when complete, leaves the patient, it 
should never be forgotten, with a skin sensitive to irritation and more 
prone to a fresh attack of the disease than one long virgin of an inflam- 
matory process. 

Such is the course of an attack of acute eczema of severe grade. 
It must be remembered, however, that the process may be mild and 
subacute from the beginning, or again that a circumscribed patch of 
skin may exhibit all the features of vesicular eczema in an acute form, 
and under the influence of appropriate treatment may satisfactorily be 
relieved in the course of a few days. Lastly, acute or subacute eczema 
may be followed by chronic forms of the disease, the one passing into 
stages of the other by scarcely definable gradations. 

Chronic Eczema. — The symptoms and pathology of chronic eczema 
are largely those of the acute form of the disease. The chief differ- 



ECZEMA. 367 

ences to be noted relate to diminished intensity of the inflammatory 
action, a marked tendency to recurrence and persistence of the process, 
and a preponderance of scaling and infiltration as contrasted with the 
active secretion and crusting of acute phases. It is important, how- 
ever, to remember that chronic eczema is not only the frequent sequel 
of such acute phases, but is prone also to recurrent exacerbations of 
acute grade, during which the serous discharges, consequent crusts, and 
angry aspect of the affected surface do not fail to reappear. The itch- 
ing so characteristic of the malady in all its manifestations is often 
more annoying than in the acute phases of the disease. 

Chronic eczema may involve a limited region of the skin, or may 
invade the entire surface of the body from the head to the feet. Rarely 
thus generally developed, it is more frequently observed upon circum- 
scribed patches of the integument, as, for example, the scrotum or the 
flexor surface of a joint, in which situation it may linger for years or 
even for a lifetime, now better and now worse, or disappear for brief 
periods only to return with each recurrence of its cause. 

Etiology. — Eczema is a disease of both sexes and of all ages. Ten- 
dencies to all disorders of the body may be inherited, but eczema, as 
such, is not an inherited disease. No child was ever born into the 
world with an eczema. Certain individuals, however, show a peculiar 
susceptibility to eczema. In these persons the disease may occur with- 
out obvious cause, and is often produced by conditions, either internal 
or external, which are ineffective in the great majority of people. It 
is noted elsewhere that eczema in certain instances is due to parasites ; 
but for the majority of cases it should, nevertheless, be classed with 
non-contagious affections. 

In many cases no cause of eczema can be discovered beyond the 
causes which operate exclusively within the skin-organ and which are 
proper to itself. These causes are necessarily obscure, and will so 
remain until we are in possession of far more knowledge than possessed 
at present as to the complex and inscrutably delicate processes by which 
innervation, nutrition, and new formation of the living matter of the 
skin are both conserved and impaired. The autonomy of the integu- 
ment must be conceded to the extent recognized in other organs of the 
body. There are diseases of the liver that are referred neither to the 
blood, to the nerves, nor to the action of poisons. There are diseases 
of the heart that are induced by neither rheumatism nor syphilis. 
When the etiology of the disorders of all the viscera is perfected that 
of the skin displaying the lesions of eczema will assuredly be more 
distinct. 

These remarks are justified by clinical facts. Eczematous affections 
may occur in individuals who are in every respect superb examples of 
good health, and whose bodies, after the most thorough and careful 
examination, fail to reveal either an external or an internal cause for 
the disorder. It is true that in a majority of cases eczema is associ- 
ated with some disturbance of the general economy, but it occurs in 
persons who are affected with every form of bodily ailment, those 
suffering from acute and chronic disorders of every viscus and system 



368 



INFLAMMATIONS. 



of the body, and even those affected with other disorders of the 
skin. 

Just what influence these varied systemic disorders may have upon 
eczema is not known. For the present they should be considered for 
the most part as either coincidences or as conditions favoring the de- 
velopment of diseases in general, eczema not excepted. By interference 
either with innervation, nutrition, development, or excretion, or with 
the performance of other important functions of the body, as well as by 
local and reflex irritation of the surface, these internal causes operate 
by inviting, aggravating, or prolonging an eczematous attack. Among 
such predisposing conditions may be named not only diseases, but also 
physiological states, such as pregnancy, lactation, and dentition; oc- 
cupations necessitating inordinate fatigue of body or of mind, espe- 
cially with the exclusion of sunlight ; and lastly substances foreign 
to the body which produce an irritative action upon the mucous sur- 
faces, such as certain dietary and medicinal articles, intestinal par- 
asites, and instruments or fluids introduced into the mucous canals, as, 
for example, the male urethra. 

The systemic conditions which occur most frequently with eczema 
are those dependent upon defects in digestion, assimilation, and excre- 
tion, such as constipation, the various forms of indigestion, rheuma- 
tism, gout, and allied conditions. In individuals suffering from these 
disorders the secretions from an eczematous surface have been found 
to contain an excess of uric acid, or have dried to form a visible crys- 
talline deposit of urates on the surface. In these so-called "gouty 
eczemas" the disease commonly occurs independently of any recog- 
nized external cause, is symmetrical, recurrent, and it may be found 
in several members of a family or in successive generations. In 
some individuals, and frequently in children, certain articles of diet 
produce a dermatitis which persists and spreads as an eczema. Gly- 
cosuria and less frequently albuminuria may be discovered before or 
after the appearance of an eczema. In the foregoing conditions, depend- 
ing upon some form or degree of malassimilation, it is probable that 
toxins or imperfectly metabolized food-products circulating in the blood 
act either directly upon the excretory glands or upon the nerve- 
endings of the skin, or indirectly through vasomotor disturbances. An 
existing eczema may be aggravated by irritation of the gastro-intestinal 
tract by means of coarse, indigestible food. This influence is explained 
usually as " reflex irritation." The same influence has been invoked 
to explain the appearance of new areas of eczema at some distance from 
the original focus of the disease. Csillag's * experiments showed that 
irritants applied to the skin produce a dermatitis at the area of con- 
tact, but at no other place, if care be taken to prevent accidental con- 
veyance of the irritant to other regions. That the nervous system is 
related closely, etiologically and pathologically, to some forms of 
eczema is recognized now by most observers. Eczema occurs in various 
organic and functional neuroses, in simple nervous exhaustion or debil- 
ity, in neuritis, neuralgia, or following injury of a nerve. It may even 
follow nervous shock. Through the action of the sympathetic and 
1 Archiv, 1902, lxiii., p. 213. 



ECZEMA. 369 

vasomotor nerves various organic diseases may cause an irritation or 
congestion of the skin, and thus contribute one or more factors to the 
production of an eczema. 

Eczema seems, in exceptional cases, to bear some relation to spas- 
modic asthma, either coexisting with that disease or its attacks regu- 
larly alternating with asthmatic paroxysms. This relation may be 
due to the exquisite sensitiveness of the skin, the mucous membranes, 
and the nervous system exhibited in some patients. 

Finally, anaemia, chlorosis, tuberculosis, scrofula, syphilis, or any 
other systemic disorder that lowers the general vitality and that of the 
skin, may favor the occurrence of eczema or of any other disease to 
which the skin may be exposed. 

The external causes of eczema are identical with those of dermatitis, 
and are chemical, mechanical, or thermal in their action. As stated 
on a preceding page, no sharp distinction can be drawn between 
eczema and any other dermatitis due to external causes, but those 
forms of dermatitis which persist after the removal of the external 
cause are probably due in part to, and are continued through, the 
action of other etiological factors, and are conveniently classed with 
eczema. It is doubtful if any of the local causes of dermatitis, acting 
for a limited period, could produce a persisting eczema without the 
cooperation of other conditions, either internal or external. The 
large majority of all externally operating causes of dermatitis fail to 
be effective in the mass of individuals. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration, they can all be 
referred to either solar light and heat, to contact with foreign bodies 
in various fluid or solid states, to toxic agencies of a widely differing 
nature, to traumatisms in varying degrees, and to the action of para- 
sites. Many of these agencies cooperate, some include others, and 
some become effective by aggravating a disease which others have 
engendered. The reader is referred to the chapters on General Etiol- 
ogy and Dermatitis for fuller consideration of this subject. It will be 
sufficient to note here that acids, alkalies, antimonial and mercurial 
compounds, mustard, sulphur, castor-oil, capsicum, arnica, turpentine, 
chloroform, ether, alcohol, and a long list of other medicaments are 
capable, when applied to the skin, of producing a dermatitis that, in 
susceptible individuals, will persist after removal of the cause, and 
may therefore be classed as an eczema. The same statement is true 
of articles manipulated in many of the trades — those, for example, 
handled by the grocer, the baker, the confectioner, the seamstress, the 
ink-manufacturer, the mason, the cook, the gardener, the laundress, the 
painter, the dyer, the printer, the tobacconist, and the chemist, Then, 
too, the eczema of the person exposed to severe cold, or to intense solar 
light and heat aided by reflection from water, or even to excessive 
artificial heat, as the fire of a furnace, illustrates the action of other 
causes named. Pressure- and friction-effects are exhibited in the 
inflammatory effects produced by contact with gaiters, the edges of 
cuffs, trusses, crutches, and corsets. 

Scratching is a fruitful cause of dermatitis where the skin is affected 
24 



370 INFLAMMATIONS. 

with pruritus as a distinct disease or as a symptom of other cutaneous 
disorders. The experiments of Torok l and Rona 2 indicate that me- 
chanical irritation of the normal skin, even in patients predisposed to 
the disease, will not produce a vesicular eczema, though in very 
sensitive skins a dermatitis with an exudate may result, and if the 
irritation be sufficiently prolonged, it may cause a lichenoid infiltration. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema whether it proceeds from the sudo- 
riparous glands in an excessive exudation of sweat Avhich is not duly 
removed by ablution, or is applied externally as a fluid in excessively 
cold or hot temperatures, or in the vapors of the popular Turkish and 
Russian baths or, yet again, be rendered irritating by saline or other 
constituents. 

The causes are at times climatic, the disease being worse in most 
people during the cold seasons. Cold winds and sudden temperature- 
changes, especially from warm to cold, will often aggravate and pro- 
long an existing eczema. 3 

The external sources of eczematous trouble named above should be 
regarded simply as suggestive illustrations. It should be borne in 
mind that every contact with the external world sufficiently severe or 
prolonged to awaken the resentment of the healthy skin may be fol- 
lowed by the protest of the latter in the shape of an eczema ; and the 
same may be true when even the most trivial external accidents occur 
to the sensitive skin of certain individuals especially prone to the 
disease. 

That many eczemas are modified in their course, and that some are 
caused wholly or in part, by various micro-organisms, is undoubtedly 
true. Aside from pus-cocci found in pustular eczema, however, no 
definite parasites have yet been demonstrated to be effective either in 
the production or in the modification of eczema. The healthy skin is 
the habitat of many forms of parasites, chiefly vegetable, and every 
skin-lesion is open to infection with any one of the many micro-organ- 
isms with which it may come in contact ; hence, it is probable that the 
disease, once begun, is modified by secondary infections of one kind or 
another. Secondary pus-infection is frequently recognized, and the 
manner in which some forms of eczema respond to antiparasitic treat- 
ment leads to the inference that some of the many micro-organisms 
found in the lesions are active in the prolongation, if not in the produc- 
tion, of the disease. Numerous parasites, including the morococcus of 
Unna, have been cultivated and described as the cause of eczema, but 
their etiological relations to the disease have not been demonstrated. 4 

1 Archiv, 1902, lxiii., p. 27. 

2 Ibid., p. 39. 

3 Cf. references under General Etiology, p. 68; also Warde, Brit. Jour. Derm., 
1903, xv., p. 349. 

4 For a full discussion of the parasitic and other causes of eczema consult the 
Transactions of the Fourth International Congress of Dermatology, Paris, 1900 
(Compt. rendu, XIII. Congr. Internat. de med., pp. 9-94) (abstr. in Brit. Jour. 
Derm., 1900, xii., p. 326) ; also papers by Morris, Brit. Jour. Derm., 1898, x., p. 359 ; 
Koberts, Ibid., 1899, xi., pp. 7 and 66; Torok, Annates, 1898, s. iii., ix., p. 1073; 
and 1899, s. iii., x., pp. 30 and 37 ; Sabouraud, Ibid., 1899, s. 3, x., p. 305 ; Leredde, 
Ibid., 1899, s. 3, x., p. 438 ; Unna, Monatshefte, 1899, xxix., p. 106 ; Galloway and 



ECZEMA. 371 

The probability that some forms of eczema are due to toxins of 
different micro-organisms is established by the experiments of Bender, 
Bockhart, and Gerlach. 1 These obseryers in a long series of controlled 
experiments found that inoculation of the normal skin with cultures 
of staphylococci produced an impetigo or a simple pyodermia, but 
when filtered bouillon cultures of the same organisms, which contained 
no cocci but only their toxins, were employed, the result was always a 
papulo-vesicular eczema of ordinary type. The primary vesicles so 
produced were sterile, but later contained staphylococci. 

Bockhart 2 believes that in individuals predisposed to eczema 
staphylococci may remain inert in the mouths of the follicles until 
some cause from without or within arouses them into activity. They 
then produce toxins which diffuse into the epidermis and produce 
eczema. The lesions so produced are invaded subsequently by cocci 
and other organisms, so that the later changes in eczema are due largely 
to other agencies. 

Pathology. — The pathological changes in eczema are those of inflam- 
mation of the skin, varying somewhat with the acuteness or chronicity 
of the process, and with the character and career of the exudate fur- 
nished in each expression of the disease. In most cases there is, first, 
a circumscribed or diffused hyperemia of the affected part followed by 
dilatation and congestion of the blood-vessels of the corium, exudation 
of serum, diapedesis of white blood-corpuscles, and oedema. 

The process probably begins in the papillary layer, from which it 
extends to the epidermis, to the deeper parts of the corium, and in 
exceptional cases inward even to the subcutaneous tissue. The cedema- 
tous infiltration may be quite extensive, producing marked swelling 
over considerable areas, or it may be slight and circumscribed. At 
times it appears only about the hair-follicles, producing perifollic- 
ular papules. The cell-infiltration about the vessels of the corium is 
formed in part of leucocytes, some of which wander outward into 
the rete, but is probably composed largely of young connective-tissue 
cells. 

The epithelial changes in eczema vary greatly with the stage, in- 
tensity, and type of the disease. It is not determined definitely if 
these changes are always dependent upon and follow the conditions 
described above in the corium, or if they are usually, or even rarely, 
primary in origin. It is probable that they are secondary to the vascu- 
lar changes in the corium, though some observers, including Unna and 
Leloir, believe that in most cases the epithelium is first affected. In 
practically all forms of eczema there is a parenchymatous oedema of the 
epithelial cells, especially of the transitional layers, as a result of which 
there is imperfect keratinization (parakeratosis) of the horny layers, the 
cells of which contain some moisture, retain imperfect nuclei, and are 

Eyre, Brit. Jour. Derm., 1900, xii., p. 307 (bibliography) ; Kromaver, Archiv, 1900, 
liii., p. 85; Scholtz et Raab, Annales, 1900, s. 4, i., p. 409; Whitfield, Brit. Jour. 
Derm., 1900, xii., p. 406 ; Schwenter-Trachsler, Monatshefte, 1903, xxxvii., p. 233; 
Engmann, American Medicine, 1902, iv., p. 769; see also chapters by Besuier, La 
Pratique Dermatologique, and Unna, Mracek's Handbuch. A brief summary is to be 
found in MacLeod's Pathology, p. 341. 

1 Monatshefte, 1901, xxxiil, p. 149. 2 Ibid., p. 421. 



372 INFLAMMATIONS. 

exfoliated in scales. In acute erythematous eczema running a brief 
course the epithelial changes may be limited to this parakeratosis, but 
in most cases they are followed by vesicle-formation in the upper part 
of the rete. The manner in which vesicles are formed is a matter of 
dispute Some observers report that the first vesicles of acute 
eczema apparently are due to the formation in a number of contig- 
uous cells of a clear space between the nucleus and the protoplasm, 
which enlarges until there is left merely a meshwork filled with serum. 
Other writers 1 state that the prickle-cells are forced apart me- 
chanically by the intercellular oedema, forming small spaces. The 
vesicles so produced maybe unilocular, but often are subdivided by 
remnants of prickle-cells into several chambers. The oedema may 
cause a separation of practically all the cells, producing Unna's 
" spongy metamorphosis " of the epidermis. The intracellular 
oedema described above follows. As a result of compression the 
prickle-cells about the vesicle may assume a spindle-shape. The 
vesicles, though usually superficially situated, may be found in any 
part of the rete. MacLeod states that they form in the region of 
least resistance, which in eczema is commonly the superficial portion 
of the prickle-cell layer, but when the oedema appears with unusual 
rapidity the greatest strain is put on the cells nearest the basal layer, 
where the vesicles then are formed. Again, the oedema may diminish 
somewhat, permitting the cells beneath the vesicles to become cornified, 
thus locating the vesicle entirely within the stratum corneum. The 
vesicles contain first serum with fibrin ; later, leucocytes in varying 
numbers, more or less degenerated epithelial cells, and nuclei. As a 
result of more active degeneration of cells, or of secondary infection, 
the vesicles become pustules, the contents of which dry on the surface, 
forming thick crusts. In very acute cases, with an abundant exudate, 
the horny layer may be raised from the rete to form vesicles or bullae. 
According to Unna, vesicles in the later stages of eczema are due solely 
to an intercellular oedema. 

In eczema rubrum the horny layer is raised from the rete and de- 
stroyed without true vesicle-formation. The rete is thus exposed 
directly to the air, or is partly covered by an amorphous coating of 
dried serum and degenerated cells. 

In the later stages of eczema there is more or less hypertrophy of 
the rete (Unna's acanthosis), with corresponding enlargement of the 
papillae, forming papules and elevated, thickened areas. In chronic 
cases the cell-infiltration and proliferation in the corium become very 
conspicuous, producing the thickening of the skin so characteristic of 
patches of chronic eczema. In these cases the papillae are larger than 
normal, and the vessels of the corium are dilated and surrounded by con- 
nective-tissue cells. The process may extend to the subcutaneous fatty 
layer, which then loses much of its fat, and becomes dense and attached 
to the skin. Hypertrophy of connective tissue and lymphatic obstruc- 
tion with elephantiasic changes may follow. In these cases the sebaceous 
and coil-glands and the hair-follicles may be partially or entirely 
destroyed by undergoing degeneration and atrophy. 

1 CJ. MacLeod, Pathology, p. 101. 



ECZEMA. 373 

The fluid exuded in eczema, in vesiculation, or in a free discbarge 
from the surface, is always characteristic. Though in the earliest 
vesicles it is a simple blood-serum, it soon becomes a yellowish-white, 
sticky, and syrupy liquid, feebly alkaline in reaction and depositing 
albumin in abundance when treated with heat and nitric acid. Exposed 
to the air, it desiccates in light-yellowish to brownish friable crusts 
resembling honey or gum. 

Increase in the pigment-particles distributed to the epithelia of the 
rete is characteristic of the chronic forms of eczema, and more espe- 
cially of those in which the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. This 
increased pigmentation is true, however, of all diseases accompanied by 
an augmented afflux of blood to any part of the body, as, for example, 
over the surfaces of joints to which for many years stimulating embro- 
cations have been applied. 

The elevation of the body-temperature in the inflamed skin is some- 
what proportioned to the rapidity of the process. In acute eczema 
such elevation may exceed 105.5° F. (41° C), while in chronic eczema 
it can scarcely be appreciated. 

The subjective sensations in eczema are due, undoubtedly, to an 
irritation of the nerve-endings in the corium and rete. It is not known 
if this nerve-irritation is secondary to other pathological changes in the 
skin, or if the nerves are primarily active in disturbing the nutrition 
and function of other tissues. 

Diagnosis. — Though of a dozen consecutive cases of eczema no two 
may look alike, yet they all have some characteristics in common and 
the diagnosis is usually attended with little difficulty. Eczema in 
its manifestations is such a protean disease and is, moreover, of such 
frequent occurrence, that it is necessary to establish a differential diag- 
nosis between it and a large number of other cutaneous disorders. The 
more important of these disorders are named below in alphabetical 
order for convenience of reference, the distinctive peculiarities of each 
being briefly appended. In making a diagnosis it must be remembered 
that eczema may coexist with any other disease of the skin, and that 
it very frequently thus complicates such cutaneous disorders as sebor- 
rhea, psoriasis, and scabies. 

Acne. — Acne occurs chiefly on the face, the neck, and the back of 
the trunk, and its pustular forms may be mistaken for eczema of the 
same localities ; but pustular acne is usually accompanied by a deeper- 
seated infiltration than the similar lesions of eczema, and this infiltra- 
tion is also generally limited to the sebaceous glands or the periglan- 
dular tissue. In eczema the itching is often severe, while in acne the 
subjective sensations are those of heat or burning. Comedones inter- 
mingled with the pustules of acne will aid in distinguishing the two. 

Erythematous eczema of the face is to be distinguished from Acne 
Rosacea by the more generalized infiltration of the former, its produc- 
tion of itching, and its greater diffusion over the face ; while acne 
rosacea is limited more often to the cheeks, nose, and brow, and to the 
region adjacent to these parts. The patch of erythematous eczema is 
" hot," that of acne rosacea is cold, to the touch. The former is seen 



374 



INFLAMMATIONS. 



in infancy, the latter is rare in that period of life. Acne rosacea in 
many cases is distinguished readily by the development of visible 
blood-vessels in the skin of the cheeks or the nasal region. Lastly, in 
erythematous eczema the eyelids may suffer, while in acne rosacea this 
is the exception. In severe forms of acne the subepidermic pus-form- 
ation and the resulting scar will prove significant. 

Dermatitis. — Dermatitis of artificial origin is to be distinguished 
from idiopathic eczema rather by its history than by special differences 
in the appearance or evolution of the lesions. In many cases the two 
affections are indistinguishable. A history of traumatism or of the 
external application of irritant or of toxic articles will often serve to 
distinguish the two. When the dermatitis has been produced by an 
externally applied irritant the resulting inflammation of the skin will 
often exactly outline the area of contact. Dermatitis of artificial pro- 
duction is usually sudden in its onset, the date of which will nearly 
correspond with the time of operation of an exciting cause. The sub- 
sidence of the symptoms after the withdrawal of the cause will also 
point to the nature of the affection. Eczema is also much more capri- 
cious in its distribution and career than dermatitis. 

Erysipelas. — Erysipelas is generally accompanied by febrile symp- 
toms ; in many cases bullae appear. The affected surface is reddened, 
much more swollen than in eczema, owing to the involvement of deeper 
tissues, and it exhibits besides a characteristic shining appearance, 
which is always absent in erythematous eczema. The line of demar- 
cation between the affected and unaffected portions of the skin is 
usually distinctly defined in erysipelas, ill defined in eczema. Erysipelas 
is an exceedingly acute affection and spreads from one point to another 
with a rapidity that is never noticed in eczema; the latter disease, 
moreover, usually exhibits under a lens its minute papules or vesicles. 
In eczema also, when occurring upon the face in the erythematous 
form, the scalp is usually spared, while erysipelas tends to invade the 
scalp and the regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperemia only, by the presence of an 
inflammatory process. The erythema simplex which advances to exu- 
dation at once transgresses the artificial line of distinction between 
the purely congestive and the purely exudative disorders. It must, 
therefore, be remembered that many eczemas begin as erythemata, and 
that clinically the latter may represent but a stage in the morbid 
process. The discharge in erythema intertrigo results from imprisoned 
or from chemically altered sweat, and will not stiffen linen as does 
the serous exudation of vesicular eczema, for example. Erythema 
multiforme, an affection really on the border-line between the two 
pathological classes here sought to be distinguished, will be recognized 
by the absence of severe itching and the recurrence of the disorder 
at certain special seasons of the year ; while Erythema papulosum, E. 
tuberosum, and E. nodosum display solid elevations of the skin-sur- 
face much exceeding in size the minute lesions of papular eczema. 

Herpes. — Eczema is so associated with the occurrence of a vesicle in 
the minds of many that other vesicular disorders are likely to be con- 



ECZEMA. 375 

founded with it. But in herpes febrilis the vesicles usually are grouped 
about the mucous outlets of the body, and when actually under observa- 
tion they exceed in size the minute and transitory lesions of vesicular 
eczema. In herpes zoster, with the limitation of the eruption in the 
course of a nerve to one side of the body and the production of grouped 
vesicles of a larger size and more persistent type, there is commonly a 
history of precedent or coincident neuralgic pain. The subjective sen- 
sation in the skin is a decided burning rather than itching, and there is 
a possibility of the subsequent production of scars. 

Impetigo. — In these forms of disease pustular lesions are usually 
isolated, do not spring from an infiltrated surface on which other lesions 
may be visible, and are unaccompanied by the intense pruritus which 
is characteristic of eczema. The pustules, moreover, are larger, and 
the resulting crusts, as a rule, are bulkier and darker colored than 
those in eczema. Again, in pustular eczema the cutaneous affection 
usually occurs in one or more patches, while in impetigo a dozen or 
more isolated pustules may be irregularly scattered over the entire 
surface of the body. In impetigo there may be a history of extension 
of the disease from one member of a family to another. 

Lichen Planus. — Papular eczema may be confounded with lichen 
planus, but in the latter disease the typical papule has an irregular or 
polygonal base ; a flat or umbilicated apex, which is covered with a thin, 
closely adherent, varnished-looking scale; and a violaceous or dull- 
crimson hue. The papules of eczema have round or oval bases, acu- 
minate or rounded summits, and are brighter red in color. They also 
form more rapidly and undergo change of type more frequently than 
the more persistent papules of lichen planus. The patches of lichen 
planus are more sharply defined than those of eczema, and are usually 
angular or linear in outline. The lesions of lichen planus on disap- 
pearing leave a characteristic brown or sepia-tinted pigmentation. 

Lupus Erythematosus. — Lupus erythematosus greatly resembles cer- 
tain forms of squamous eczema. The great chronicity of lupus; the 
firm attachment of the scales ; the symmetrical distribution of many 
patches upon the face ; the association of some forms of the disease with 
the sebaceous glands ; the definite border of each involved area ; and, 
above all, the discovery of a cicatrix left by the morbid processes will 
sufficiently distinguish the disorder. In eczema there are usually itch- 
ing, often vesiculation, more rapid extension of the borders of a single 
patch, and scales much more loosely attached than in erythematous lupus. 
The scales of eczema are never provided, as in lupus erythematosus, 
with stalactitiform plugs on the inferior surface. 

Mycosis Fungoi'des. — Mycosis fungoides, in its earliest stages, may 
be indistinguishable clinically from some forms of localized or even 
generalized eczema. As a rule, however, the early erythematous and 
eczematoid lesions of mycosis fungoi'des can be recognized by their 
characteristic gyrate outlines, assuming, as they do, the shape of a 
kidney, horseshoe, half-moon, and other fantastic, more or less circmate, 
forms. These figures may change frequently in form and location, or 
may disappear spontaneously, to return in the same or in new sites. 
They differ further from eczema in being located on any or every part 



376 



INFLAMMA TIONS. 






of the body, independently of external influences, and in failing to 
respond to treatment during months or years. After the formation of 
characteristic thickened and elevated plaques the diagnosis is not 
difficult. 

Lupus Vulgaris. — Lupus vulgaris is readily distinguished from eczema 
by its more chronic career, by its larger papules and tubercles of dark 
reddish-brown hue, and by every one of its destructive processes, none 
of which is ever recognized in eczema. 

Pediculosis. — As eczema is often induced by lice upon the head, the 
pubes, or the clothing, it is always necessary to exclude the operation 
of such causes for both diagnostic and therapeutic purposes. Eczema 
limited to the pubic region or to the pubic and axillary regions should 
suggest careful examination of the skin and the hairs for the discovery 
of the crab-louse. As for the pediculus corporis, it should be the rule 
of the physician, invariable and never to be forgotten (whatever the 
social position or refinement of his patient), to search in a suspected 
case for evidence of the parasite upon the under surface of the clothing 
worn next the skin, at the instant of its removal and while the patient 
supposes him to be busied with the inspection of the cutaneous lesions. 
The excoriations produced by scratching wounds inflicted by body- 
lice are usually out of all proportion to the amount of skin-disease 
present; and this excoriation is the most significant of all symptoms 
next to the discovery of the corpus delicti. Head-lice may precede or 
may follow eczema of the scalp, but either they or their ova (nits), 
clinging in numbers to the hairs, will be visible to him who looks 
carefully for them. 

Pemphigus and Pityriasis Rubra. — The large isolated bullae of pem- 
phigus vulgaris are never seen in eczema. In pemphigus foliaceus 
the lesions are succeeded by the formation of pastry-like crusts, serous 
exudation, considerable soreness, and the eventual production of an 
extensive and usually fatal exfoliative dermatitis. Marasmus gradually 
or in some cases rapidly ensues, while, as a rule, itching and infiltration 
are not present. The disease known as pityriasis rubra is equally rare 
and fatal, and, though unattended with the production of bullae, is char- 
acterized by an abundant epidermic exfoliation ; itching and infiltration 
being either entirely wanting or insignificant in comparison with the 
other symptoms present. The scales, too, are papery, large, and thin ; 
there is no vesiculation and moisture, and little, if any, infiltration of 
the skin. The integument is, moreover, of a uniformly reddish hue. 
Both pemphigus foliaceus and pityriasis rubra are particularly liable 
to be complicated with chills or with uncontrollable diarrhoea. With- 
out question, many of the reported cases of so-called " pityriasis rubra " 
are instances of squamous eczema or of simple exfoliative dermatitis. 
Here the localization of the disease to one or more patches upon the 
body, the severe itching, and the distinct infiltration of the patch point 
to the eczematous character of the disease. Observation of such patients 
will finally convince the physician, in many cases, that there is occa- 
sional weeping from the surface. 

Pityriasis Rubra Pilaris. — Often this disease resembles in a high 
degree, and it may indeed be confused with, the squamous forms of 



ECZEMA. 377 

eczema. In general there are not found in eczema characteristic 
lichenoid papules formed about the hair-follicles, with their hyper- 
keratinized cap sheathing the follicular orifice. JSor is the selection 
of the extremities, and especially the dorsal aspect of the fingers, char- 
acteristic of eczema. In eczema there are usually distinct marks of 
scratching that may wholly be wanting in pityriasis rubra pilaris ; and 
the latter has in most cases a more chronic course. 

Prurigo. — In the prurigo of Hebra, a disease exceedingly rare in 
America, there are infiltration, intense itching, and numerous minute 
and larger papules. But this disease usually occurs within a year or 
two after birth and lasts for a lifetime, extending generally oyer the 
greater part of the body, sparing only the palms and soles (which 
eczema does not), and is accompanied by inguinal adenopathy. 

Pruritus. — In pruritus, often confounded with prurigo, there is itch- 
ing without lesion of the skin save that induced by the nails to relieye 
the sensation. Hence, pruritus without scratching will not reveal a 
cutaneous disease, while pruritus with scratching will exhibit either 
excoriations or an eczema induced by the attacks made upon the skin. 
The latter condition, however, is rarely noted. The distinction will 
be clear when it is remembered, first, that pruritus is usually of a 
paroxysmal character, being worse regularly at certain hours or seasons ; 
second, that pruritus not originating in a cutaneous lesion, but indirectly 
producing the latter by the medium of the finger-nails, never exhibits 
as much cutaneous excoriation as the skin bitten by lice or attacked 
with eczema. The impressive features here are always the dispropor- 
tion between the complaint of the patient and the visible symptoms, 
and the vast preponderance of all lesions in those regions of the body 
most accessible to the hands, such as the anterior faces of the limbs, 
the genital region, the lower belly, etc. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 
Variations in type from one to the other furnish many obscure 
cases. 

The following are the chief diagnostic points in psoriasis: sharp 
definition of contour of patch; abundance and lustrous hue of the 
scales; absence of moisture; vascularity of tissue beneath the scales; 
sites of election on posterior aspect of the trunk and extensor surfaces 
of limbs; chronicity in course; uniformity of lesions; and usually 
absence of itching. In eczema there are an ill-defined contour ; usually 
scanty scales not having a nacreous hue; a preference for the flexor 
surfaces of the extremities, though the disease may occur in any por- 
tion of the body ; generally, at some period in its course, a history of 
moisture; polymorphism, as regards lesions; and a marked intensity 
of subjective sensations. Upon the scalp psoriasis is prone to extend 
beyond the hairy border in a fillet stretching across the upper portion 
of the forehead, thence irregularly down in front of the ears; while 
eczema of the face, when the scalp is also invaded, departs boldly from 
the hairy parts to the lower forehead, the lips, nose, cheeks, or chin, 
regions which are relatively spared by psoriasis. Finally, the two 
diseases, in doubtful cases, will generally be distinguished by carefully 
searching the entire surface of the body, upon some part of which in 



378 



INFLAMMATIONS. 



psoriasis there will usually be discovered a tell-tale patch of typicr.l 
appearance. 

Scabies. — Scabies is really an artificial eczema induced by the incur- 
sions of the acarus scabiei, and its lesions are thus those of eczema. In 
scabies, however, the pruritus is intense and the recently formed 
papules, vesicles, and pustules are more distinct and isolated than in 
eczema. The discovery of the presence of the parasite, especially if 
there be a history of contagion, and the localization of the disease in its 
sites of preference, will at once determine the diagnosis. Scabies never 
attacks the scalp. Its sites of preference are in both sexes the fingers, 
hands, wrists, and axillae ; in women the breast and the nipple ; in men 
the penis ; and in children the buttocks. The presence of the acarian 
furrow, if the disease has existed for some time, and the appearance 
of minute blackish dots or points upon or about the lesions, usually 
suffice to establish the nature of the disease. 

Seborrhoea. — Seborrhoea and eczema may coexist, either disease pre- 
ceding the other. Typical forms of each are readily distinguished. 
In eczema there are infiltration and much consequent itching; in seb- 
orrhoea there is neither. The scales of seborrhoea are more voluminous 
and greasy than those of eczema, are freely shed from the surface, and 
are seated usually upon an integument of scarcely altered hue; in 
eczema the scales are dry, scanty, and more firmly attached to an 
hypersemic base. Seborrhoea of the hairy parts is generally symmet- 
rically diffused; eczema, though occurring with ill-defined contour, is 
rarely as symmetrical, usually more acute, and is seldom followed by 
alopecia. Upon non-hairy portions of the body the same distinctions 
can to a great extent be observed. The crusts of eczema removed from 
the face generally disclose beneath them an oozing surface, while the 
under surface of these crusts never exhibits the stalactite-like prolonga- 
tions which pass from the under surface of seborrhoei'c crusts into the 
patulous orifices of the excretory ducts of the sebaceous glands. In 
eczema seborrhoeicum the features of both diseases are almost com- 
pletely fused. 

Sycosis. — Both the hyphogenous and the coccogenous forms of 
sycosis are limited to the region of the beard, while eczema of 
the hairy portions of the face will usually be found to affect other 
parts. In eczema the itching is severe, the exudation spreads beyond 
the limits of the beard, and the discharge is characteristic ; while in 
both forms of sycosis there is less oozing and the subjective symptoms 
are trivial. The discovery of the parasite in the root or the shaft of 
the hair will at once distinguish the hyphogenous forms of the disease. 
In coccogenous sycosis each pustule is perforated by a hair. Eczema 
limited to the region of the beard is even rarer than the two varieties 
of sycosis. The circumscribed indurations and tuberculations of the 
affection produced by the trichophytons, as well as the loosening of the 
hairs in their follicles, constitute further distinctive differences. 

Syphilis. — Several syphilitic eruptions resemble certain forms of 
eczema. In the eruptions due to syphilis, however, there is usually a 
history of infection ; of involvement of the glands and mucous surfaces; 
of ulceration and cicatrices in advanced periods, and, especially in the 



ECZEMA. 379 

case of infants with an eczema-like eruption, and a history of snuffles. 
The intense itching of eczema is characteristic of no one of the syphil- 
ides, and the latter are remarkable for their tendency to occur with a 
circular or partially circular outline, and to be covered with bulky mal- 
odorous crusts. A point worthy of note is that compared with chronic 
eczematous affections a syphilitic eruption limited for an equal period 
of time to one locality will often ulcerate or exhibit evidences of repair 
by scar-tissue, no such results occurring in eczema. 

Syphilis of the palms and soles exhibits very distinct outlines in 
the usually circular, circumscribed, and deeply infiltrated patches 
present, which are often symmetrical in development, or are at least 
situated on both sides of the body even if more fully developed 
upon one limb. Syphilitic pustules upon the scalp usually rise above 
superficial but w T ell-defined ulcers. Syphilitic eruptions encircling the 
mouth in children are less angry-looking and formidable than those of 
severe eczema of the same region, being often made up of flattened pap- 
ules, moist or scaling, grouped in circles about the lips, with mucous 
patches at the angles. 

Tinea Circinata. — In ringworm there should be a history of con- 
tagion, microscopical discovery of the vegetable parasite, distinct con- 
tour of all separate patches, and absence of marked subjective sensa- 
tions and of discharge. These symptoms are not those of eczema. In 
ringworm of the scalp the hairs loosened in their follicles are usually 
either brittle or are actually broken at a short distance from the scalp ; 
the scales are fine, dirty white, and not torn from the surface by the 
finger-nails. In eczema the hairs are unaffected, and their extraction 
is productive of pain. In ringworm of the body the patches are dis- 
tinctly circular, are more scaly or papular at periphery than centre, 
and, moreover, yield with promptness to the action of a parasiticide. 
Occurring about the thighs and anogenital region, the disease may be 
complicated by eczema, but the characteristic " festooning " of the 
advancing border of the patch downward along the thigh, or upward 
over the pubes, will suggest a microscopical examination of the scales 
scraped from the surface. 

Tinea Favosa. — The large, friable, dirty crusts of an old and 
neglected favus of the scalp might be mistaken for the crusts of 
eczema of the same part ; but here the exudation is slight, and there is 
little scratching, as in eczema, hence no history of discharge. The odor, 
moreover, is characteristic. In case of uncertainty a careful search 
would reveal a few characteristic cup-shaped and yellow crusts, or the 
microscope would demonstrate the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will re- 
veal, beneath the epidermal plates, the spores and filaments of the 
fungus which produces the ailment. From eczema the disease is 
easily distinguished by the absence of infiltration and of any history 
of inflammation ; by the very slight subjective sensation it produces ; 
by its peculiar fawn- to chocolate-colored, slightly yellowish patches, 
which are covered with superficial furfuraceous scales, are limited to the 
covered parts of the body and often to the anterior surface of the trunk, 
and are readily removed by the action of a parasiticide. 



380 INFLAMMATIONS. 

Urticaria. — In papular forms of the disease there may be a re- 
semblance to eczema. This resemblance is more marked in children, 
as here the two diseases may be intermingled. Characteristic wheals 
often occur by the side of eczematous patches, but, as a rule, urticarial 
lesions are less grouped, more generally disseminated, more evanescent, 
and much less scratched. 

Treatment. — The treatment of eczema usually presents a complicated 
problem. The causes of the disease are numerous, frequently obscure, 
and when discovered are often difficult to remove. Eczema shows 
little tendency to spontaneous recovery, but tends rather to persist, to 
spread to contiguous or distant parts of the body, and to recur. Al- 
though many cases of the disease respond well to local treatment alone 
if the affected surface can be given absolute rest and kept constantly 
covered with the desired dressing, such ideal treatment can rarely be 
carried out except in hospital-patients. Moreover, in many cases of 
eczema the general health of the patient must be improved before local 
treatment can be effective. The nutrition and functional activity of 
the skin depend largely upon the condition of the general system, for 
the skin is but one of many organs in a complex organism. It follows 
also that every serious disease of the skin must interfere more or less 
with the general health. The fear that too rapid a cure of eczema may 
result in disease of deeper-seated organs is baseless. The sudden 
improvement or disappearance of an acute eczema coincidently with the 
development of a pneumonia or other grave disorder may be explained 
by the rapid withdrawal of a large amount of blood from the skin- 
surface to the newly congested organ. The improvement in the eczema 
is thus a result and not a cause of the deeper-seated disease. 

The treatment of eczema requires both local and constitutional 
management. 

(A) Constitutional Treatment. — In many cases internal treatment 
may be wholly ignored, and eczema be successfully controlled by local 
measures alone, even though there be coincident systemic disease. 
Often, however, the eczema is an external expression or result of other 
pathological conditions which must be removed before the eczema can 
be permanently cured. These systemic disorders vary widely, ranging 
through the whole field of internal medicine, including hygiene. In 
these pages a few suggestions only can be given regarding the internal 
treatment of eczema, much being left to the practitioner's knowledge 
of general medicine. It is often necessary not only to relieve disease 
of other organs, but also to study the patient's temperament, habits of 
eating, drinking, bathing, sleeping, etc., before an obscure cause of a 
stubborn eczema can be found and removed. 

Diet. — No absolute rule can be laid down regarding the diet in 
eczema. Each individual should be given the quantity and quality of 
food that will best nourish his body without interfering with digestion 
and elimination. The anaemic, strumous, and poorly nourished subject 
should be given sufficient fresh beef, mutton, eggs, milk, cream, vege- 
tables, and other nourishing foods. Cod-liver oil, butter, and other 
fats, when easily digested, are of special value, as also are the various 



ECZEMA. 381 

malt-preparations, particularly when digestion of the carbohydrates is 
at fault. In the plethoric, the overfed, the gouty, and in those suf- 
fering from faulty digestion and elimination, a diet restricted to the 
lowest point consistent with the health of the individual is often of the 
greatest importance. In these cases excellent results are obtained by 
limiting the patient to a diet of bread and milk, or of milk alone, or of 
milk and seltzer-water, for several weeks. In general, the diet allowed 
the eczematous patient should be limited to the most digestible articles 
of food, and should exclude those (a list of which is given in the 
chapter on Urticaria) capable of exciting cutaneous irritation. Cooked 
vegetables, fruits, and a small quantity of fresh meats may be per- 
mitted ; but starchy articles in excess, hot breads and cakes, pastry, 
confectionery, cheese, pickles and pickled meats, cucumbers, cabbage 
(both raw and cooked), parsnips, turnips, beans, oatmeal, cracked 
wheat, pease, celery, shell-fish, salted fish and meats, pork, and veal 
should be avoided. Milk, when not the source of constipation, may 
be drunk, but not during the meal-hour. Coffee, tea, and cocoa are in 
the doubtful list, as they are positively injurious to some patients and 
apparently without effect in others. Tobacco should always be for- 
bidden to male patients suffering from a serious eczematous attack. 
Alcohol in every form is contraindicated save in condition of debility, 
or in case of its previous habitual use in moderation by persons of 
advanced years. In gouty patients the dietary should be of the 
strictest appropriate to that condition, and in diabetic eczema the regi- 
men proper in glycosuria is observed with great benefit in most cases. 

Internal Medication. — There are no specifics for eczema. Such 
remedies only should be given as are indicated by the general condi- 
tion of the individual. Over-medication and uncalled-for dosing 
with " blood " medicines is a common error in the management of this 
disease. The number of patients presenting themselves for treatment 
of eczema, both in dispensaries and hospitals and in private practice, 
who have aggravated their condition by medicaments they have swal- 
lowed is incredibly large. Men and women, infants and adults, those 
who have been under the charge of physicians, and those who have 
purchased drugs of an apothecary at the suggestion of the latter or 
of their friends, exhibit patches of acute or of chronic eczema aggra- 
vated by the injudicious use of arsenic, potassium iodide, potassium 
bromide, Donovan's solution, and other harmful preparations con- 
tained in the various " blood-purifying " remedies sold in the shops. 
The practitioner whose patient comes to him after making trial of any 
such remedies is strongly urged to set aside the operation of such mis- 
chievous agents, and to watch the eruption carefully while their effect 
is vanishing. The result is often marvellous. The chief object of the 
constitutional, and also of the local, treatment of eczema is to remove 
all sources of irritation to the inflamed skin. 

An attempt to relieve pruritus by the use of anodynes internally 
is rarely necessary, and usually aggravates the disorder. Opium and 
its preparations increase the pruritus, though in full doses they relieve 
temporarily. With some patients, and especially children, full doses 
of quinine may relieve itching. Less frequently full doses of calcium 



382 INFLAMMA TIONS. 

chloride, largely diluted with water, may serve the same purpose. Id 
an emergency, chloral, phenacetin, sulphonal, or even tne bromides, 
may be given, but it must be remembered that, like opium, they are all 
liable to aggravate the pruritus after the first anodyne effect has passed. 
In the management of acute eczema cooling draughts are useful ; 
and in all cases occurring in patients who are plethoric, who are con- 
stipated, or who suffer from other symptoms of imperfect excretion, 
aperients and cathartics are needed. Often a brisk mercurial purga- 
tive in the form of blue mass or the compound cathartic pill may be 
ordered at the outset. Five grains of blue mass or three grains of 
calomel may be given each night, followed by a saline laxative in the 
morning, for ten days or two weeks. A tenth of a grain of calomel 
combined with sodium bicarbonate may be given every half hour for 
a day or two, and then three or four times daily for two weeks or 
longer, if at the same time salines are used to keep the bowels freely 
open. The rhubarb-and-soda mixture answers well in some cases. 
Podophyllin, or the familiar combination, nux vomica, aloes, and bella- 
donna, may be substituted for these articles. The saline cathartics, 
whether employed in medicinal formulae or in natural mineral waters, 
such as the Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are 
exceedingly useful in the management of most cases. The following 
is a valuable combination often advised for cases in which both iron 
and magnesium sulphate are indicated : 



R 



Magnes. sulphat., 


33; 


60 


Acid, sulphur, dil., 


ftfj; 


8 


Ferri sulph., 


Bss; 




Sodii chlorid., 


3j; 


4 


Cardamom, tinct. comp., 


f3j; 


4 


Aq. dest., 


ad Oss ; 


240 



66 



M. 

Filtra. Sig. * A tablespoonful before breakfast in a tumblerful of cool or of hot 
water. 

An excellent remedy 'for some cases is from 15 to 20 drops of a fluid 
containing 2 parts of the fluid extract of cascara sagrada to 1 part 
each of glycerin and tincture of aloes, the dose to be taken at bedtime 
or before breakfast in a small glassful of water. A full dose of castor- 
oil on retiring is an excellent remedy in many neurotic cases, and may 
be continued for weeks if needed. 

In some cases of renal derangement the alkaline diuretics are indi- 
cated, such as potassium acetate, carbonate, or citrate, administered 
with nitre, squills, caffein, or lithium benzoate in from 3 to 5 grain 
(0.26-0.33) doses before meals, and in gouty cases colchicum, Vichy 
water, etc. Distilled or other pure water, or in suitable cases the 
alkaline spring-waters, taken in large quantities before meals and 
between meals, are very valuable as diuretics and as a means of encour- 
aging elimination. In patients suffering from acid dyspepsia liquor 
potassse, sodium bicarbonate, or ammonium carbonate may be required. 
Salol and other intestinal antiseptics are often of value. 

Aloes and iron, or aloes and ergot, are indicated in special cases. 
Where diuretics and alkalies are both indicated the following formula 
is often of service : 



ECZEMA. 383 

R Magnes. sulphat., ^ss; 15 

Magnes. carbouat., 3 j ; 4 

Colchici tinct., f"3ss; 2 

Menth. pip. ol., nUj ; 2 

Aq. dest., f gvj ; 180 M. 

Sig. Two tablespoonfuls in a wineglassful of water every three or four hours. 

Cod-liver oil is indicated in all cases of struma and tuberculosis ; 
calcium phosphate in bronchitis ; iron in anaemia and chlorosis ; strych- 
nine, hypophosphites, and other nerve-tonics in neurotic cases. 

In fleshy children affected with eczema capitis calomel internally is 
a valuable remedy, from \ grain to 2 grains (0.03-0.133) of calomel, 
with 2 to 3 (0.13-0.20) of rhubarb, rubbed up with 5 (0.33), of cal- 
cined magnesia, may be given once in a day to an infant ; or ^ of a 
grain (0.003) of calomel, rubbed up with sugar of milk, may be given, 
three times daily, for ten or twelve days. Small doses of the un spiced 
syrup of rhubarb, with or without magnesia, may be required for the 
constipation of infants, or from 1 to 3 drachms (4.-12.) each of pow- 
dered rhubarb and sodium bicarbonate in 4 ounces (120.) of pepper- 
mint-water, of which a teaspoonful may be administered two or three 
times or oftener daily. Quinine, strychnine, syrup of ferrous iodide, 
and wine of iron may also be used with advantage when indicated in 
these little patients. 

In full closes, and especially in children, quinine sometimes acts as 
an antipruritic. For the same purpose calcium chloride in full doses 
answers well in some cases. Antimony in small doses as an alterative 
and nerve-tonic or in large doses to reduce vascular pressure is often 
of value. 

Beside those enumerated above may be named the following articles, 
which, after internal administration, have been reported as efficient in 
the hands of various authorities : calx sulphurata, viola tricolor,, sodium 
hyposulphite, ichthyol,- chrysarobin, tar, carbolic acid, sulphur, pilo- 
carpine, and turpentine. 

Arsenic, which has been so largely employed by the general prac- 
titioner in eczema and in other disorders of the skin, is an uncertain 
remedy in all cutaneous diseases; it is equally uncertain in eczema, 
and has unquestionably aggravated as many cases as it has relieved. 
Its value in some chronic papular and squamous forms of the disease is 
undoubted, and in small doses as a nerve-tonic it is often of value, but 
it should never be given in acute cases or where there is any digestive 
disturbance. If arsenic, which certainly does possess an influence over 
the skin, has been demonstrated to have little or no value in the large 
proportion of all cases of eczema, what can be said for the host of other 
drugs, too commonly employed for a similar purpose, that are inferior 
to arsenic in their cutaneous effects ? Sunlight, fresh air, ' suitable 
clothing, and due regime as to pleasure and business, must be, for 
many patients, controlled by the physician. These agencies do not cure 
eczema; but they do much to aid in its management; they may do 
more, if neglected, to furnish sources of its aggravation. Crocker 
advocates counter-irritation over the spine — over the nape of the neck 
for eczemas of the upper segment of the body ; over the dorso-lumbar 



384 INFLAMMATIONS. 

vertebrae for the lower parts. Jackson has used the ice-bag with 
advantage in the same way. Counter-irritation of the corresponding 
part of the lateral half of the body for the relief of an eczematous patch 
of long standing limited strictly to the other side may also be employed 
in rare cases. 

(B) Local Treatment. — Local treatment is of value in all cases of 
eczema, is usually imperative, and often is the only treatment necessary. 
The remedies recommended for external application in the various 
forms and phases of eczema are so numerous and varied that barely to 
mention all would require many pages ; and not even the expert can 
be sufficiently familiar with them all to use each intelligently. A com- 
paratively small number of remedies skilfully handled will suffice in 
all but rare cases. It often happens that in a given type of the dis- 
ease a treatment which one physician uses with brilliant success fails 
utterly to serve a fellow-practitioner who is equally skilful, but who is 
less familiar with this particular method. One of the most common 
errors in the local treatment of eczema lies in the frequency with 
which, in a difficult case, a succession of new medicaments is tried 
instead of studying more carefully the details of application of familiar 
remedies. It must not be forgotten that each individual skin, like its 
possessor, has its idiosyncrasies. A remedy that in a given type of 
the disease will commonly give prompt relief, may in others prove of 
no benefit and even aggravate the condition. An idiosyncrasy may 
exist forbidding the use of particular drugs, such as carbolic acid, 
glycerin, resorcin, etc., or it may prevent the employment of certain 
classes of applications, as, for example, ointments, powders, lotions, 
etc. The choice of remedies must further be influenced in each case 
by a consideration of the type or phase, severity, and duration of the 
disease, of the region and extent of surface involved, of the age, occu- 
pation, and climatic and other surroundings of the patient. 

The general objects and principles of treatment in eczema may con- 
veniently be grouped under the following heads : (1) exclusion of 
all sources of irritation to the skin ; (2) relief from pruritus, burning, 
and other morbid sensations ; (3) antiseptic dressing ; (4) reduction of 
local congestion in acute, and stimulation of circulation in chronic, 
cases ; (5) repair of the horny layer in acute, and destruction of the 
thickened and abnormally keratinized horny layer in chronic, forms of 
the disease. 

1. Exclusion of all Sources of Irritation. — This is the 
most important, the most varied, and often the most difficult and 
complex problem of all. Its full solution, however, will in the 
majority of cases fulfil all the other indications for treatment. Fre- 
quently a simple protective dressing is all that is required ; more com- 
monly the object is not so readily attained. The irritation of the skin 
due to its malnutrition or to conditions of ill health must be relieved 
in accordance with the principles of internal medicine, as has been 
indicated in discussing the internal treatment of eczema. 

The exclusion of all sources of irritation necessitates, secondly, the 
avoidance of all injurious external contacts. Only gross ignorance or 
carelessness will overlook the fact that the inflamed skin, like the in- 



ECZEMA. 385 

flamed bone or the inflamed bladder, calls imperatively for rest. The 
prevalent idea, however, is that the patient with an inflamed joint 
retires to his couch or bed, while the patient with an eczema, if his dis- 
ease be not so formidable as to necessitate temporary withdrawal from 
the pursuits of business or of pleasure, belongs always to the peri- 
patetic class. He consults a physician, swallows some medicine, 
anoints his eczematous skin with a salve, and returns to the vocation 
in which his complaint was begotten. The baker goes to his baking ; 
the seamstress still pushes her needle through the dyed fabrics which 
first injured her hand ; the man with an eczema of the thigh walks the 
street with his trowser-leg rubbing the affected surface ; the nursing- 
mother with an eczema of the inframammary region still suffers the 
milk chemically altered in the heat of summer to Aoav over the tender 
surface of the breast, or in the case of her infant affected with eczema 
stuffs the folds of a coarse diaper half laundered or yet covered with 
the dejection from the bowels between its thighs and over the anal 
region. When a patient from necessity or from choice continues in 
the vocation or conditions which are largely or wholly responsible for 
the persistence of his malady he should distinctly understand that his 
recovery will be much slower and more uncertain than it would be 
with the rest and protection that every inflamed organ demands. 

Next is involved the exclusion of all topical irritants (in the hands 
of either physician or patient) designed to relieve the disorder, but 
having a precisely opposite effect. The number and variety of these 
medicaments are far from being commonly appreciated ; some are useful 
in advanced stages of the disorder, and harmful in its earlier periods. 
These articles, which are generally ordered by persons with a limited 
experience in diseases of the skin, represent a long list of stimulating 
and astringent ointments. Some are employed in sheer ignorance of 
their effects, as, for example, crude petroleum, strong acids and alka- 
lies, silver nitrate, turpentine, and concentrated solutions of corrosive 
sublimate, intended to " burn out " the disease. 

Lastly, the exclusion of all sources of irritation necessitates protecting 
the involved surface from the excoriations and other traumatisms pro- 
duced by scratching, rubbing, and excessive washing of the eczematous 
skin, and from the irritation caused by exposure of the inflamed sur- 
face to the air. The various applications and protective dressings here 
serve their purpose, but in the case of adults some restraint to pre- 
vent rubbing and scratching is also needed ; in the case of infants this 
restraint may need to be enforced. Fixed dressings are often of great 
value in immobilizing a part, or in preventing friction, bruising, or 
other injury to the inflamed surface. A. light elbow-splint to prevent 
flexion of the joint often is of service in keeping the fingers from the 
face. Most patients have to be repeatedly and forcibly impressed 
with the fact that a few minutes of scratching or rubbing, or one 
untimely washing of the inflamed surface, or its unnecessary expos- 
ure to the air may undo all that has been gained in several days of 
patient and successful treatment. This exclusion of all sources of 
irritation to the skin is essential to the proper treatment of every case 
of eczema. 

25 






386 INFLA MM A TIONS. 

The great importance of rest and freedom from irritation of all sorts 
in eczema is well illustrated by the newborn infant, whose sensitive 
skin responds early to its first harsh acquaintance with the outer 
world by an explosion of eczema. It is a fact of importance that 
no child is born into the world eczematous. If the nervous system 
alone were responsible for infantile eczema, such a result might occur, 
for that system is not only capable in intra-uterine life of producing 
club-foot and other deformities, but also of influencing skin-disorders. 
In the case of pigmentary moles visible at birth the lesions are often 
located along the distribution of one or more nerves. . If the blood 
alone were responsible for eczema, the foetus surely might display its 
lesions, as it does those of syphilis. Animal poisons, as those* of 
variola and scarlatina, do not spare the unborn child ; nor is it exempt 
from certain diseases of the integument that are generally regarded 
as due solely to tissue-changes, since newborn infants are occasionally 
seen affected with ichthyosis or sclerema neonatorum. 

Why is the tender skin of the foetus exempt from every form of 
eczema, and the tender skin of the infant accessible to each by such 
various approaches ? Will it be responded that the child has begun to 
respire and digest for itself; that it has become suddenly strumous, 
dartrous, rheumic, arthritic, gouty, or herpetic ; that its standard of 
health is impaired ; that it is suffering from assimilative, nutritive, or 
nervous debility, or from any one of the other numberless perturba- 
tions to which eczema maybe ascribed? While nutritive and other 
constitutional changes undoubtedly have their influence, it would cer- 
tainly seem that the difference between the child unborn and the child 
born is, as regards eczema, a difference chiefly of skin-protection and 
skin-exposure. The former enjoys what White has aptly termed a 
" prolonged, placid, subaqueous life." Anointed with unguent and 
immersed in its water-bath of grateful temperature, its skin cannot be 
fretted to produce an eczema. The child, abruptly and often rudely 
brought into contact with the outer world, may speedily exhibit the 
most formidable symptoms of the disease. 

If any apology be needed for the space devoted to this part of an 
exceedingly interesting subject, it must be based upon the great fre- 
quency of the disease, the wide diffusion of erroneous doctrines re- 
specting its nature and the method of its management, and the mischief 
resulting from the too common aggravation of the malady in its earliest 
manifestations, due largely, on the part of both physicians and laymen, 
to a lack of appreciation of the fact that an inflamed skin needs rest 
and protection as much as does any other similarly affected organ of 
the body. 

2. Relief of Pruritus. — The itching, burning, and other sensa- 
tions which accompany eczema are usually largely or entirely allayed 
by the complete protection of the skin from irritation. Antipruritics 
are, however, frequently desirable and necessary. Among the best are 
carbolic acid, hydrocyanic acid, camphor, menthol, and salicylic acid, 
each in the strength of 0.5 to 2 per cent, (rarely stronger) in lotions, 
ointments, jellies, pastes, etc. Saturated solutions of boric acid, or the 
lead-and-opium wash, answer in many acute cases. If a remedy does 



ECZEMA. 387 

not relieve the itching, it should be changed for one that will, unless 
the fault lies in the method of application. The most common error 
in the use of local remedies is found in the five- and ten-minute, or 
longer, intervals during which the skin is not protected, either as a 
matter of convenience or of appearance or as a result of carelessness 
in removing and reapplying the dressings. Exposure to the air for a 
few seconds only of an acutely inflamed surface may be sufficient to 
arouse a violent attack of itching or burning. The relief of pruritus 
by the use of drugs internally is considered under the head of internal 
medication. 

The necessity of relief is so imperious that at times the itching 
overshadows all other symptoms of the disease. He who has never 
studied the case of a man, a woman, or a child, possessed with a furious 
impulse to relieve an intense eczematous pruritus has not yet completed 
an education in medicine. This fury, for such it really is, has been 
likened to the sexual orgasm, with which it is undoubtedly allied, as 
the two are not rarely coincident when there is severe anal or genital 
itching. The features of the patient are drawn ; he is but half- 
conscious of his ejaculations and surroundings ; with his nails, or other 
object which he employs, he attacks the too vulnerable skin with an 
incalculable savagery. In these exaggerated paroxysms nothing but 
blood will suffice for his relief. Not until the torn and wounded sur- 
face oozes with red drops at every point does he emit the sigh which 
indicates that his desire is satisfied. Men and women forcibly with- 
held from doing themselves this severe damage will at times exhibit 
the muscular spasm, facial expression, and movements of body scarcely 
distinguishable from the symptoms of petit mat in an epileptic seizure. 

3. Antiseptic Dressing. — It is not known to what extent eczema 
may be due to, or may be modified by, the various micro-organisms 
that come in contact with the skin, but severe cases are undoubtedly 
complicated and prolonged by the action of such bacteria, and it is well 
in every case, when possible, to prevent their activity. Simple protec- 
tion does much to accomplish this end, while, fortunately, most of the 
remedies used as antipruritics are also more or less parasiticidal. In 
certain forms of the disease, such as seborrheal eczema, sulphur, resorcin, 
and other parasiticides are necessary. 

4. Relief of Local Congestion. — This is accomplished by posi- 
tion, compression, internal treatment, and largely by the removal of 
external irritation. Occasionally a direct astringent action may be 
obtained by the use of lead- water, lime-water, or by some of the rapidly 
drying jellies or glycerogelatin preparations. In chronic eczema pas- 
sive congestion is removed by means of stimulating washes, soaps, 
ointments, etc. 

5. Repair of the Epidermis. — If the preceding indications are 
fulfilled, repair takes place naturally. It may be aided and hastened 
somewhat in suitable cases by the use of very mildly stimulating 
remedies, such as weak preparations of sulphur, resorcin, ichthyol, 
thiol, tar, etc. In chronic cases with much thickening of the epidermis 
the abnormally and imperfectly keratinized horny layer must be de- 
stroyed and removed before the process of repair can begin. For this 



388 



INFLAMMATIONS. 



purpose salicylic acid in ointment is especially valuable. Other reme- 
dies used for the purpose are tar, sulphur, resorcin, chrysarobin, pyro- 
gallol, etc. 

Local Treatment of Different Types and Phases of Eczema. 1. Acute 
and Subacute Eczema. — In selecting remedies for use on the acutely 
inflamed integument it is always best to begin with one that is mild 
and soothing, and to make the application to a small surface only, until 
it can be determined that the preparation is going to operate favorably 
in the case at hand. So greatly do individuals differ in their response to 
a given remedy that it is often well to order an alternative treatment 
in case the first does not prove satisfactory. A remedy that induces 
comfort and brings relief to the patient will usually do good, while 
one that irritates will almost invariably do harm. One of the most 
important things to be remembered in the treatment of acute eczema is 
that the acutely inflamed skin does not tolerate pure water. The skin 
should be washed as little as possible, and this without soap and with 
soft water or with water that has been softened by the addition of 
borax, soda, bran, oatmeal, gelatin, or other demulcent, as outlined in 
the description of baths in the chapter on General Therapeutics. Hot 
water thus prepared and applied either as a lotion, a bath, a fomenta- 
tion, or by sponging (without rubbing), is frequently grateful and alle- 
viates the itching. If employed at all, its use should immediately be 
followed, as soon as the part is carefully dried, by the medicament 
selected for topical application, such as an oily or fatty substance, or a 
dusting-powder. In exceptional cases the continuous application of 
the cold pack may be of value, or, when it can be obtained, the con- 
tinuous immersion of the inflamed surface, which has been previously 
covered with an ointment, in water of a constant temperature. Dur- 
ing the acute stages cleansing of the skin can usually be accomplished 
best by the use of olive- or other oil. For the removal of crusts and 
other accumulations a bland oil may be poured frequently over the 
surface with gentle inunction or be applied on lint or gauze. 

Even the oils, however, are at times sources of irritation. They 
are made more soothing if combined with an equal part of liquor 
calcis to form a liniment, as in Carron oil, constituted of equal parts 
of linseed-oil and lime-water. For the linseed-oil, which has a ten- 
dency to dry and form a dense coating on the surface, it is frequently 
better to substitute olive-oil, oil of sweet almonds, cod-liver oil, palm- 
oil, or lard-oil, flavored very slightly with bergamot or with lavender 
to correct the disagreeable odor. The addition of 1 per cent, of car- 
bolic acid makes the mixture antipruritic and mildly antiseptic. A 
thick emulsion may be formed by shaking together fresh lard and 
lime-water. In many cases the value of these dressings is greatly 
enhanced by surrounding the whole with oiled silk or other im- 
permeable tissue. Such dressing should not be applied continuously 
for many hours at a time for fear of macerating and weakening the 
skin. 

Poultices. — Flaxseed, linseed, starch, or other poultices may 
in exceptional cases be applied for a few hours at a time to soften 
crusts and other accumulations on the surface. They should not 



ECZEMA. 389 

be retained long enough to produce congestion and maceration of the 
skin. 

Powdees are useful in acute erythematous or papular eczema, in 
intertrigo, and occasionally in vesicular forms of the disease. Applied 
to a discharging surface, powders tend to form coherent crusts which 
retain secretions and are therefore irritating to the skin. In early 
stages when the discharge is slight, powders will sometimes succeed in 
wholly arresting the secretion. For this purpose they are of special 
value in mild forms of intertrigo. To prevent friction of underwear 
upon the skin the meshes may be filled with a fine powder. In eczema 
of the hands the gloves may be treated in the same way. For absorp- 
tive purposes magnesium carbonate is one of the most effective. For 
use on dry surfaces zinc stearate, plain or combined with boric acid, 
salicylic acid, thiol, acetanilid, etc., is very valuable on account of its 
lightness, and because it will adhere to any surface over which it is 
lightly rubbed with the hand. Among other excellent powders may 
be mentioned talcum, lycopodium, starch, rice-flour, " cimolite," bis- 
muth subnitrate, zinc oxide, and calamin. The following formulae are 
good : 



R Acid, boric, 3ij ; 8 

Talc, 3vj ; 24 

01. ros., q. s. q. s. 

R Acid, boric, 3ij ; 8 

Zinc, stearat., 3ij ; 8 

Talc, 3ss ; 16 

Ol. amygdal. amar., q. s. q. s. 



M. 



M. 



Anderson's powder and others containing camphor relieve pruritus 
better than the simpler powders, but are usually too stimulating and 
irritating for use in acute cases. In the preparation of dusting-powders 
it is of the utmost importance that they be made impalpable by sifting 
them carefully through silk bolting-cloth, as they are sources of irrita- 
tion when they contain gritty particles. Only the best and finest 
grades of zinc oxide, talcum, calamin, and other powders should be 
employed, as many of the coarser grades found in the market cannot be 
rendered fine enough for use by any means at the command of the 
average chemist. 

Lotions are probably the most valuable preparations in acute and 
subacute eczema, and in some of the chronic forms of the disease. 
They are especially valuable in moist eczema, where it is necessary to 
protect the surface and relieve the itching, and at the same time to avoid 
the retention of secretions by the dressing. The chief drawback to the 
use of a lotion lies in the necessity of its frequent application to pre- 
vent drying. This objection may be removed partially by the addi- 
tion of 2 per cent, or more of glycerin or of tragacanth-mucilage. 
The effect of a lotion is further prolonged by the addition of some 
impalpable and inert or astringent powder, such as talcum, zinc oxide, 
bismuth subnitrate, or calamin. The powder, temporarily held in 
suspension by shaking the lotion immediately before each application, 
is thus left as a deposit upon the skin. A similar but less uniformly 



390 INFLAMMATIONS. 

diffused effect is produced by the use of a dusting-powder immediately 
after the application of the lotion. In moist eczemas a better method 
is to keep the lotion constantly applied on gauze or other material in the 
form of wet dressings. Great care must be exercised in the removal 
of such dressings after they have become dry, for fear of wounding the 
skin. An effective method is to put a single layer next the surface, 
which is removed but once or twice in twenty-four hours or only when 
soiled or stiffened by excretions, while a number of outer and thicker 
layers may be changed frequently in order to keep the dressing wet. 

Lotions may be sedative, astringent, or stimulating. Many and 
varied formulae are recommended, but few only of the most useful and 
typical are given here, together with some suggestions as to their 
occasional modification. One of the most useful lotions, and one that 
is easily procured, is the following : 



R 



Acid, carbolic, 


By; 


2 


Zinc, oxid., 


33; 


4 


Glycerin., 


3ij; 


8 


Aq. calcis, 


q. s. ad gvnj ; 


q. s. ad 240 



M. 



The quantity of any one or all of the first three ingredients may be 
increased or diminished as desired. Where carbolic acid does not act 
favorably dilute hydrocyanic acid may be substituted. The zinc may 
be replaced partially or Avholly by one of the other powders mentioned 
above. Tragacanth-mucilage may be used instead of glycerin, or both 
may be omitted and half of the lime-water be replaced by an equal 
quantity of elder-flower water. By the use of one or more of these 
suggested changes may be formed the well-known Starting lotion and 
its modifications, and the several compound zinc-oxide lotions ; among 
the most desirable are : 

R 



R 



Occasionally neither carbolic acid nor hydrocyanic acid has the 
desired antipruritic effect, even when increased in strength to 5 per 
cent., or both may be contraindicated for some reason. In such cases 
from 1 to 3 per cent, of menthol, camphor, or chloral may be added, 
with sufficient alcohol to hold them in solution. With these additions 
the lotion becomes more or less stimulating and must be used in acute 
cases with great caution. 

The following lead-and-opium wash is as useful as the various zinc 
oxide lotions, and in weeping cases with burning or hyperesthesia is 
usually more acceptable. 



Acid, hydrocyan. dil., 


3ss-3ij ; 


2-8 




Zinc, oxid., ) 
Calamin., ) 


aa 3j ; 


4 




Aq. calcis, 1 
Aq. sambuci, ) 


aa £iv ; 


120 


M 


Acid, carbolic, 


3ss-3ij ; 


2-8 




Bismuth, subnit., 


ffl; 


4 




Tragacanth., 


gr. xl; 


2 


66 


Aq. calcis, 


3vnj ; 


240 


M 



ECZEMA. 391 



R Tinctur. opii, ^ss ; 15 

Liquor, plumbi subacetat. 
dilut., q. s. ad ^viij ; q. s. ad 240 



M. 



To this may be added, as in the case of the zinc oxide lotion, gly- 
cerin, boric acid to saturation, zinc oxide, or other powder to be left on 
the skin as a deposit, or from \ to 1 ounce (15. to 30.) of tincture 
of camphor if this is well tolerated and a more decided antipruritic 
effect is desired. 

A saturated solution of boric acid to which has been added 2 per 
cent, or more of glycerin or tragacanth-mucilage is an excellent appli- 
cation in moist eczema, and especially in suppurating forms. A weak 
solution of potassium permanganate is both antiseptic and antipruritic. 
Black wash pure or diluted is effectual in many moist forms of eczema, 
as are 1 to 10 per cent, solutions of ichthyol and thiol. Excellent 
lotions for soothing effect are made by adding 1 to 2 drachms (4.-8.) 
of sodium bicarbonate or biborate to a quart (1000.) of thin oatmeal- 
gruel or of marshmallow-decoction. For a dry, irritable, and itching 
ezcema, Boeck recommends the following : 



Talc, ) 
Amyli, } 


aa ^ij ; 


60 


Glycerin., 


3vj; 


24 


Liq. plumb, subacet. diL, 


3iv; 


120 



M. 

This is to be diluted with 2 parts of water, and applied with cotton or 
a brush. This lotion is decidedly cooling, but is not indicated in moist 
eczema. 

The COMBINED USE OF LOTIONS AND OINTMENTS will often give 

good results. The black wash as recommended by Duhring, White, 
and others is often effective in acute vesicular eczema. The part is 
bathed for fifteen or twenty minutes two or three times a day with 
the wash, the sediment allowed to remain on the skin, and the whole 
covered with a piece of gauze or soft cloth on which has been spread a 
thick layer of zinc oxide or other simple ointment. The lead-water 
or the zinc oxide lotions may be used in the same way with simple 
ointments or pastes. 

Any one of the zinc oxide lotions described above may be combined 
with an equal quantity of almond-, olive-, or other oil to form a Lini- 
ment. These combinations are especially good in acutely inflamed 
surfaces of considerable extent. As has been stated, they are also 
useful for cleansing the surface of crusts and other accumulations. To 
this end their action can be hastened and made more effective if an 
impermeable dressing be superimposed. For therapeutic purposes, 
however, the rubber and other impermeable dressings are rarely called 
for in acute eczema. 

For subacute and indolent stages of eczema and for some acute cases 
mildly stimulating and stronger antipruritic lotions containing tar, car- 
bolic acid, menthol, camphor, chloral, and alcohol may be used. They 
should be tried cautiously and diluted at first. As a rule, they give 
best results when applied for a few moments several times a day, the 



392 INFLA MM A TIONS. 

part being kept covered in the interval with an ointment or other pro- 
tective dressing. The following formulae, which may be modified to 
suit individual cases, are to be recommended : 

R Acid, carbolic, ^iss-gss ; 6-15 

Glycerin., 3ij ; 8 

Menthol., Sj-^ss ; 4-15 

Spirit, vin. rect., q. s. ; M. 

Aq. destill., q. s. ad ^viij ; q. s. ad 240 



R Liq. picis alkalinus, 3ss-,£ij ; 2-8 

Glycerin., £ij ; 8 

Aq. destill., q. s. ad ^viij ; q. s. ad 240 



M. 



Liquor carbonis detergens or Duhring's compound tincture of coal- 
tar (these preparations are described under Chronic Eczema) may be 
substituted for the liquor picis alkalinus. The fluid extract of grin- 
delia robusta in the strength of from 1 to 2 per cent, in water is 
recommended by Duhring for some forms of subacute papular eczema. 
It should be used with caution, as it frequently irritates the skin. 
Hutchinson recommends the following in dry, subacute eczema : 



R 



Liq. plumb, subacet., 


3ss; 


2 


Liq. carb. detergentis, 


3ss; 


2 


Aq. destill., 


q. s. ad gviij; 


q. s. ad 240 



M. 



Ointments are not, as a rule, well tolerated by an acutely inflamed 
skin, and are commonly more useful in subacute and chronic eczema, 
but there are many exceptions to the rule, and occasionally even an 
acute vesicular eczema is best relieved by use of an ointment. In the 
application of ointments care should be taken that they are properly 
and freshly prepared, and that the debris of one dressing is carefully 
removed before another application is made. Strata of any ointment, 
the older next the skin possibly rancid and having imprisoned beneath 
them pus or other products of disease are a source of positive harm. 
In acute, and especially in weeping, eczemas an ointment is best applied 
by spreading it evenly on gauze, lint, or other soft material, which can 
then be laid upon the part. The salve-muslins devised by Unna 
furnish an excellent substitute for ointments; they are clean and effec- 
tive, and in every way admirable if they can be procured fresh. They 
are, in this country, expensive, and as they deteriorate rapidly it is 
often difficult to obtain them in proper condition for use. 

Among the best ointments for use on the acutely inflamed skin is 
the well-known diachylon ointment of Hebra. It is prepared as 
follows : to 14 ounces of the best olive-oil are added 1 pound of water, 
and the whole heated to boiling on a water-bath ; 3 ounces and 6 drachms 
of finely powdered litharge are sifted slowly into the liquid, which is 
then boiled and stirred constantly until all particles of litharge have 
disappeared and there is formed a perfectly homogeneous mass. During 
the cooking water is occasionally added as required, and the whole 



ECZEMA. 393 

evaporated to the desired consistence. The stirring is to be continued 
until the ointment is cold. While the mass is cooling 1 drop of oil of 
roses or of oil of lavender is added to each 2 ounces of ointment. 
"When properly prepared the Hebra ointment is perfectly homogeneous, 
is of a light-yellowish color, and is of the consistency of butter. It is 
technically known as the " Unguentum diachyli albi " of Hebra. The 
simple ointment often becomes rancid in two or three weeks, but it may 
be preserved for months by the addition of 0.5 per cent, of carbolic acid 
or formalin. 

Duh ring has modified this ointment as follows : 1 part of pure dry 
lead oxide is rubbed down with 1 part of water, and well mixed with 8 
parts of the best olive-oil. The mixture is stirred for about two hours 
over a w T ater-bath near the boiling-point, and is then cooled with 
constant stirring until the proper consistence is obtained. The oint- 
ment has been modified by Piffard, and after him by Kaposi, in com- 
bining equal parts of lead-plaster and vaselin. It may be imitated 
fairly well by melting together 3 or 4 parts of olive-oil and 4 of 
diachylon plaster, and stirring until cool. 

The Hebra ointment, though useful often in full strength and even 
to the exclusion of other pomades, may often be combined with others 
with manifest advantage. Thus, 1 or 2 drachms (4.-8.) of it may be 
added to the ounce (30.) of lard, cold-cream salve, or cerate, with or 
without the addition of another drachm or two (4.-8.) of zinc oxide 
ointment. 

The officinal zinc oxide ointment is an acceptable preparation in 
many acute cases ; equal parts of this and the Hebra ointment make 
an excellent combination. Any one of these ointments may be reduced 
with from one to three times its volume of lanolin, vaselin, or cold- 
cream salve. The following formula gives an excellent soothing and 
protective ointment : 



R Bismuth, oxid., 
Vaselin., 
01. oliv., 
Cerse alb. 
01. ros., 



} 



3j; 


4 


5J; 


30 


3iij; 


12 


q. s. 


q.s. 



M. 



Other bland and soothing ointments may be made by combining in 
various proportions cold-cream salve, lanolin, vaselin, lard, and simple 
cerate. The cerates are made sufficiently soft for gentle manipulation 
by adding 1 or 2 drachms (4.-8. to 30.) of glycerin or oil to each 
ounce of ointment, and they may be flavored with lavender, rosemary, 
or bergamont, as preferred. These simple bases may be stiffened and 
rendered somewhat astringent by the addition of from 10 grains to a 
drachm (0.60 to 4.) or more of bismuth subnitrate or subcarbonate, zinc 
oxide, or calamin to the ounce (30.). A very thin base may be prepared 
by mixing equal parts of lanolin, olive-oil, and glycerin. This is espe- 
cially valuable for use on hairy surfaces. A creamy and cooling base 
is Unna's "refrigerant ointment," which contains lanolin, 10; lard, 20, 
and rose-water, from 30 to 60 parts. Any of the above bases may be 
medicated as desired ; the most frequent addition being from 5 to 10 



394 INFLAMMATIONS. 

grains f 0.30-0. 68) of carbolic, boric, or salicylic acid, or a similar quan- 
tity of calomel or white precipitate to the ounce (30.) of salve. With 
these unguents may be named glycerole of starch, cucumber ointment, 
emulsion of sweet almonds, decoction of Irish moss, and Hardy's 
formula — 2 parts of zinc oxide, 8 of glycerin, 30 of cold-cream salve, 
and 15 drops of tincture of benzoin. 

The oleate of bismuth or of zinc is prepared by rubbing up 1 drachm 
(4.) of the oxide of either metal with 8 (30.) drachms of oleic acid, and 
allowing the mixture to stand for two hours. It is afterward heated 
on a water-bath, where 10 drachms (40.) of vaselin and 3 (12.) of wax 
are dissolved in it, and the whole stirred until cold. This ointment 
is especially useful when employed in papular forms of eczema. In 
pustular eczema ointments containing iodoform, boric acid, iodol, aris- 
tol, or europhen are indicated. 

Pastes are especially valuable in subacute eczema, and are often 
tolerated in acute forms of the trouble better than an ointment. A 
thick paste is rarely indicated in moist eczema, as it prevents escape 
of the discharge from the surface. Pastes are more cleanly and 
adhesive, furnish better protection, are more drying, and require less 
frequent applications than ointments. They are formed by combining 
a simple powder with an ointment-base, and may be medicated by the 
addition of various remedies. The following paste recommended by 
Lassar may be taken as a type : 






R Amyl., 

Zinc, oxid., 
Vaselin., 



S«; 


8 


3ij; 


8 


^ss; 


15 



M. 



The substitution of talc for the starch in the above gives a paste 
with less tendency to concrete in lumps on the skin. Duhring uses 
boric acid in place of the starch, and thus produces a stiff and adherent 
paste. A very smooth and pleasant combination, and one that is also 
fairly stiff and adherent, is made of equal parts of talc, zinc oxide, 
vaselin, and lanolin. These pastes serve as bases to which various 
medicaments may be added. Those most commonly used in acute and 
subacute eczema contain boric, salicylic, and carbolic acids, in the 
strength of from 1 to 5 per cent. ; calomel, white precipitate, ichthyol, 
and thiol in similar proportions. Other remedies may be employed 
according to the indications. As an adherent and drying paste Duhr- 
ing recommends : 

R Lanolin., 
Paraffin., 
Cerae alb., 
Aq. destill., g j ; 30 M. 

The lanolin, paraffin, and wax are thoroughly mixed before the water 
is added. A good drying and soothing paste, recommended by Morris, 
is made of equal parts of almond- or olive-oil, lime-water, and zinc 
oxide. Unna recommends a paste prepared by mixing 1 ounce of 
zinc oxide w T ith 2 ounces (30.-60.) each of glycerin and mucilage. 
To either of these pastes may be added 1 per cent, of carbolic or 



5ij; 


60 


3j; 


30 


Si; 


4 


%i; 


30 



ECZEMA. 395 

salicylic acid. Other good bases are found in Elliot's bassorin-paste, 
or Unna's gelanthum, both of which are described in the chapter on 
General Therapeutics. 

The Glycogelatins render excellent service in all dry forms of 
eczema, in which simply protection is required. Certain remedies may 
also be incorporated, such as 1 or 2 per cent, of ichthyol or thiol. A 
convenient formula is the following : 

R Gelatin, alb., ) aa §j; 30 

Zinc, oxid., } 



Or 



Glycerin., 3Jss ; 45 

Aq. destill., §iij ; 90 

R Gelatin, alb., Sijss; 10 

Zinc, oxid., 3v ; 20 

Glycerin, £j I 30 

Aq. destill, 3x; 40 



M. 



M. 



The ingredients are mixed on a hot water-bath and when cool may 
be cut in pieces of convenient size for use. Before application a 
sufficient quantity is placed on a hot water-bath, or in a dish placed in 
a receptacle containing hot water, and applied with a brush. It dries 
somewhat slowly and it is well after two or three minutes to pat the 
surface with cotton or to cover it completely with gauze. By increas- 
ing the quantity of glycerin a softer and more slowly drying prepara- 
tion is formed. By lessening the quantity of glycerin and increasing 
that of the zinc oxide or gelatin a firmer and more rapidly drying 
product is obtained. Though these glycogelatins serve their best 
purpose in the dry forms of the disease, there are few forms of 
eczema in which they may not at times be used with benefit. In sub- 
acute and indolent types Pick's gelatin sublimate is useful. This is 
prepared by mixing 30 grammes of gelatin with sufficient water to 
liquefy it on a water-bath, and evaporating to 75 grammes ; 25 grammes 
of glycerin and 5 centigrammes of corrosive sublimate are then added. 
The product must be melted before applying. 

In acute erythematous eczema Pick's Tragacanth Varnish ("lini- 
mentum exsiccans") is a very acceptable remedy in that it is easily 
applied without heating, dries quickly, is clean, and distinctly cooling. 
It is composed of tragacanth, 5; glycerin, 2; and boiling water, 93 
parts. To this may be added from J to 2 per cent, of boric or car- 
bolic acid, or from 2 to 5 per cent, of some simple powder, such as 
zinc oxide. The tragacanth must be soaked for several hours in a part 
of the water and thoroughly triturated before the other ingredients are 
added. Stelwagon l prefers a varnish containing zinc oxide, 2 parts ; 
glycerin, 1 part ; and mucilage of acacia, 5 to 8 parts, as it dries 
quicker than the tragacanth preparation. Elliot's bassorin paste 2 is 
an excellent vehicle of the same order, but is not obtained so readily 
from the chemists. 

2. Subacute Eczema. — Attention has already been called to the fact 

1 Diseases of the Skin, p. 294. 

2 Jour. Cutan. Dis., 1891, ix, p. 48, and 1892, x., p. 184. 



396 INFLAMMATIONS. 

that no sharp line can be drawn between acute, subacute, and chronic 
eczema, the degree of inflammation in any given case varying from 
time to time. Most acute cases, however, are followed by a longer or 
shorter period of subacute or chronic inflammation. In proportion as 
the disease progresses to the subacute or chronic stage the various 
topical medicaments employed may be changed in character so as to 
produce an astringent or stimulating effect upon the part. The utmost 
skill and prudence, however, are needed at this juncture, and changes 
should be made cautiously, for it is at this time that the disorder is 
readily awakened to renewed activity, a turn of affairs which is espe- 
cially annoying to the patient, and particularly so to the practitioner 
if there be a suspicion (truth to tell, often too well founded) that the 
aggravation has been due to the treatment. 

Again, many cases of eczema are subacute and indolent from the 
beginning, yet are liable at any time to present acute manifestations ; 
consequently in beginning the treatment of an apparently subacute case 
it is well to use mild measures first, gradually changing to those stronger 
and more stimulating. 

The treatment of subacute eczema varies from that of the acute type 
chiefly in demanding more stimulating remedies and those having a 
greater antipruritic effect. For this purpose many of the substances 
already recommended for acute eczema may be employed, but in in- 
creased strength. In this phase of the disorder pastes are especially 
valuable, as are also the glycogelatins, though occasionally lotions and 
powders produce the best results. On the other hand, cases occur in 
which ointments make the best applications. When milder measures 
will not succeed in a given case the stronger remedies recommended for 
chronic eczema should be employed. 

3. Chronic Eczema. — The general principles of local treatment of 
chronic eczema are those of the acute form of the disease except that 
stronger and more stimulating remedies are used. It must be remem- 
bered that many chronic eczemas are subject to acute exacerbations, 
when milder and soothing treatment must be adopted for a time. 
Moreover, chronic eczema appears in such varied phases in different 
individuals, and in the same individual in successive attacks, that it is 
impossible to select certain formulae and declare that these will be of 
benefit in a given type of the disease. It is only by a careful observa- 
tion of the general principles and objects of the treatment of eczema, 
discussed in the preceding pages, that the varied conditions can be 
successfully treated. 

Cleansing of the skin should be accomplished according to 
directions already given, by means of oils or liniments, though in 
chronic eczema more vigorous measures can frequently be employed, 
including the occasional use of soap and water, some densely infiltrated 
patches tolerating and even being benefited by a daily washing. For 
this purpose a good toilet-soap, or, when the skin will permit, tincture 
of green soap may be used. The Sarg glycerin soap is an admira- 
ble substitute for these articles when the skin is tender and where an 
elegant toilet-preparation can be ordered. The crusts and scales once 
removed, subsequent topical applications can be made as required in 
each case. 



ECZEMA. 397 

Powders are useful in chronic as in acute eczema for mechanical 
protection, to prevent friction between apposed skin-surfaces or be- 
tween the skin and clothing. They are often of value when dusted and 
patted over a paste, thus making a thicker and more cleanly dressing, 
and one less likely than a paste to be rubbed off. The Anderson and 
other antipruritic powders are frequently serviceable for application 
during the day, when other dressings cannot well be employed on 
account of the patient's occupation. 

Lotions are of less value than in acute eczema, but are often use- 
ful for temporary purposes after the skin has been unduly irritated 
by other dressings. Stimulating lotions or solutions are sometimes 
painted on the skin and allowed to dry, or are used for a few minutes 
each day, the surface in the intervals being covered with an ointment. 

Ointments are the preparations most used, especially in the dry, 
scaly forms of the disease, in which penetration of the remedy is 
desired. To serve this end, they should be gently rubbed into the sur- 
face, which is later covered with more of the same ointment spread on 
gauze or a soft cloth. 

Pastes often answer better than ointments, especially Avhen protec- 
tion and drying of the surface are the chief objects of treatment. In 
combination with powders as described above, they furnish convenient 
and effectual applications in most cases of chronic eczema. In many 
dry forms of the disease either plain or medicated Glycogelatins 
form the best application. They are of special value in dispensary 
and other cases in which the physician does not wish to entrust the 
dressing to the patient, as a gelatin-dressing may often be left in place 
for several days or a week. For the application of tar, chrysarobin, 
salicylic acid, and a few other remedies to small areas, Collodion and 
Fluid Gutta-percha (Traumaticin) form convenient and cleanly 
vehicles. 

Applications in chronic eczema, as a rule, should be more antipru- 
ritic and more stimulating than in acute and subacute phases of the dis- 
ease. The remedies recommended above may be used in increased 
strength. This is especially true of the drugs classed as antipruritics, 
such as carbolic acid, creosote, camphor, menthol, and chloral. 

One of the most useful remedies in chronic eczema is, Salicylic 
Acid. It is antipruritic and is very effective in destroying thickened 
areas of dry horny epidermis. It may be incorporated in the strength 
of from 2 to 10 or even 20 per cent., in most of the ointments, pastes, 
and plasters recommended in the preceding pages. In the glycogela- 
tins more than 2 or 3 per cent, cannot be used without the addi- 
tion of a fat, preferably 5 per cent, of fresh lard. For small areas of 
infiltration with marked thickening of the horny layer salicylic acid is 
best used with Duhring's modifications of Pick's "salicylated soap 
plaster." The acid has a tendency to soften the plaster if employed in 
strength above 5 per cent. Duhring's formula? are as follows : 

R 



M. 



Emplast. saponis (U. S. P.) 






liquefact., 


3«j; 


90 


Olei olivse opt., 


f 3ij ; 


10 


Acid, salicylici, 


3ss; 


2 



398 INFLAMMATIONS. 

For a 5 per cent, plaster : 

B Emplast. saponis (U. S. P.), Bj ; SOI 

Olei olivse, n\,xxiy; 160 

Acid, salicylici, gr. xxiv; 1160 M. 

For a 10 per cent, plaster : 

B Emplast. saponis (U. S. P.) 

liquefact., ^j ; 301 

Acid, salicylici, gr. xlviij ; 3120 M. 

For a 20 per cent, plaster : 

B Emplast. plumbi (U. S. P.), Sj J 301 

Cerse flavae, gr. xlviij ; 3 20 

Acid, salicylici, gr. cv ; 7) M. 

Plasters made according to the above formulae are adhesive, and are 
firm enough to be moulded and kept in rolls. For large surfaces they 
should be warmed before applying, to make them spread easily. Resorcin 
and other remedies may be substituted for salicylic acid, but resorcin 
has a tendency to stiffen the plaster and requires the addition of oil. 
Unna's salicylated gutta-percha plaster-mulls make elegant substitutes 
for the above, but they are expensive and not always obtainable in this 
country. They, moreover, deteriorate rapidly, and if not fresh are not 
serviceable. 

Tar. — This is one of the most valuable remedies, when tolerated by 
the skin, for the treatment of chronic eczema. The preparations most 
commonly employed are* pix liquida (pine-tar), oleum rusci (oil of white 
birch), oleum cadinum (oil of cade), and terebinthina Canadensis (bal- 
sam of fir). Oil of cade, as found in most of the shops, is inferior to 
oleum rusci. The tars are best applied in the form of ointments, but 
are occasionally painted over the affected surface in a liquid state with 
a camel's-hair brush. From l to 2 drachms (2.-8.) of tar, in com- 
bination with a suitable quantity of potassium subcarbonate, are suffi- 
cient to add to 1 ounce (32.) of ointment, the proportions suggested 
being varied to suit the requirements of each case. 

In beginning the use of tar with any individual, weak preparations 
should first be employed, and the strength be gradually increased until 
tolerance of the skin is determined, as an acute dermatitis not infre- 
quently follows the application of stronger preparations. A convenient 
method is to order one jar of a fairly strong tar ointment, and another 
of the zinc oxide, the Hebra, or other simple salve. Before the first 
application the patient takes a sufficient quantity of the simple oint- 
ment in the palm of one hand and mixes with it a very small propor- 
tion of the tarry preparation. If no irritation follows this application, 
the amount of tar can be gradually increased with each dressing until 
enough is used to relieve the itching and to cause the disappearance 
of the infiltrated area, after which a simple paste or powder may be 
employed until the skin has regained its normal strength and resist- 
ance. If the application at any time causes an acute dermatitis, sim- 
pler remedies for a time must be substituted. To accomplish the best 



ECZEMA. 399 

results, tar ointments should be rubbed well into the skin or liquid 
preparations painted on. Sometimes it is well to permit the application 
to accumulate until thrown off by exfoliation ; but more commonly, 
and especially if there be signs of irritation, it is better to cleanse the 
skin with oil or with soap and water, according to indications, before 
each application. 

The following formulae are illustrations of the manner of compound- 
ing the various preparations of tar : 

R 01. rusci (vel cadini), 3ss-3iij ; 2-121 

Potass, subcarbonat., 7)j-3ss ; 1.33-2 

Unguent, aq. ros., §j ; 30[ M. 

Ft. ungt. 

For the potassic subcarbonate ^ to 1 drachm (2.-4.) of zinc oxide 
may be substituted, or from 2 to 4 grains (0.133-0.266) of red mercuric 
oxide, or yet ^ scruple (0.66) of mild chloride. The vehicle, also, 
of such ointments may be vaselin, lanolin, simple cerate, or ^ ounce 
(16.) of either in combination with an equal quantity of diachylon 
ointment. 

Of fluid preparations may be mentioned alcoholic solutions of tar, 
\ ounce (10.) of the latter to the pint (500.) of alcohol ; and in cases 
in which the detersive action of soap is also needed sapo viridis may 
be added as follows : 



R 



Picis liquidae, 


f Sj-Sii ; 


30-60 


Sapon. virid., 


f ,?jss-?nj ; 


45-90 


Glycerin., 


fffl; 


30 


Spt. vin. rectif., 


f 3viij ; 


240 


01. rosmarin., 


f3ss; 


2 



M. 



Sig. To be rubbed gently into the skin with a flannel rag. 



Bulkley devised an alkaline solution of tar and caustic potassa, 
which is especially serviceable, as it is miscible with water in all 
proportions, and which is constituted as follows : 

R Picis liquidae, f ^ij ; 60 

Potassae causticae, ^j ; 30 

Aq. destillat., |v; 150 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar 
with friction. 

Sig. " Liquor picis alkalinus." To be used diluted as a lotion. 

Of this solution 1 drachm (4.) or more may be added to a pint 
(500.) of water. As an ointment, the same quantity of the solution 
may be added to the ounce (30.) of cold-cream salve, lanolin, or 
vaselin. It should be remembered, however, that the caustic alkali 
renders this preparation exceedingly irritating to a sensitive skin, and 
it should be employed with caution upon any untested surface. 

An excellent fluid preparation is Duhring's "compound tincture of 
coal-tar," prepared according to the following formula : " Coal-tar 



400 INFLAMMATIONS. 

(1 part) should be digested with tincture of quillaja (6 parts), with 
frequent agitation for not less than eight days, preferably for a longer 
period, and finally filtered. The resultant product is a brown-black 
tincture which, upon the addition of water, forms a cleanly yellowish 
emulsion, the color and certain other characters varying with the 
variety of coal-tar used. The strength of the tincture of quillaja 
should be 1 to 4 with 95 per cent, alcohol." Five to fifteen minims 
to the ounce of water is the strength recommended for use. 

The formula recommended by Spender, and described in the chap- 
ter on General Therapeutics, is a useful means of testing the efficacy 
of tar upon an eczematous surface. Olive-oil or cod-liver oil may be 
combined with equal parts of one of the tarry preparations and rubbed 
into the eczematous skin. When fluid or semifluid compounds of tar 
are needed upon the scalp 1 drachm (4.) of the article selected may be 
rubbed up with an equal quantity of glycerin and added to 6 ounces 
of cologne- water (180.). Creolin is very similar in its action to tar 
and is miscible with water. 

Hebra disclaimed any special value for sulphur in eczemas uncom- 
plicated by the acarus scabiei, but in Wilkinson's and other ointments 
it serves a good purpose. The following formula supplies an ointment 
rather less severe that has practical efficacy in chronic eczema : 



B Picis liqnid. (vel. ol. rusci). 

Adipis, 

01. olivse, 
Misce et adde : 


3iv; 120 

& ; so 

£ss ; 15 


Terebinth. Canadens., ) -- z . S r, qa 
Sulphur, flor., j aa & ; aa 30 
Sig. To be applied three times daily with a soft brush. 



M. 



To this formula may be added green soap if a stronger effect is 
desired. 

Ointments and pastes containing 10 to 30 grains (0.60-2.) of sulphur, 
and 7 to 15 grains (0.33 to 1.) of salicylic acid in similar proportions 
often give good results in circumscribed, infiltrated patches of eczema 
which show tendencies to occasional moisture and crusting, Oint- 
ments containing from 1 to 4 per cent, of sulphur favor keratoplasia. 

Ichthyol and thiol, in ointments of the strength of 10 per cent, and 
less, or in aqueous lotions containing from 5 to 50 per cent, of the 
drug, are useful in localized patches of the disease, especially of the 
papular and scaling varieties. Ammonium sulpho-ichthyol is prefer- 
able to the natrium compound. Its influence upon the skin seems to 
resemble both that of the tars and of chrysarobin. Unna's varnish 
containing ichthyol is convenient, as it dries rapidly and is easily 
removed by washing. It is prepared as follows : 40 parts of starch are 
mixed with 100 parts of water, to which are added 40 parts of ichthyol ; 
after thorough trituration there are added 1J parts of a concentrated 
solution of albumin which should be prepared at a temperature low 
enough to prevent coagulation. 

Other remedies which may be added to ointments, pastes, or plasters 
in strength varying from 1 to 10 per cent, for the treatment of chronic 
eczema are resorcin, chrysarobin, pyrogallol, calomel, and white precipi- 



ECZEMA. 401 

tate. Occasionally systemic intoxication has followed the use of these 
remedies over large surfaces, and they are adapted best to employment 
on small areas. The three first named stain the skin and clothing. 
Other preparations of mercury may be employed with advantage in 
some cases. The use of resorcin in seborrheal eczema is considered 
with that subject. 

In persistent areas w r ith marked infiltration of the skin radio- 
therapy often gives excellent results. We have found it of value 
most frequently in the dry scaling forms of the disease, but it is indi- 
cated also in moist forms with infiltration, and especially in cases in 
which suppuration is present. The technique is the same as that 
recommended for psoriasis. 

An effective method of treating circumscribed thickened patches of 
eczema is the following : a piece of green soap as large as a walnut is 
spread upon a flannel rag, and rubbed into the eczematous part for 
several minutes, pressing firmly the while, and from time to time 
dipping it into water in order to produce lather. The duration and 
firmness of the rubbing depend chiefly upon the amount of infil- 
tration present, but to some extent upon the general condition of the 
skin. The production of an acute dermatitis by too severe treatment 
should be avoided. Following the soap-rubbing the part is washed 
free from suds with water, carefully dried, and the oil or ointment 
selected for topical use immediately applied on strips of muslin, which 
are neatly bandaged to the part. Hebra's diachylon ointment is one 
of the best for this purpose. The soap must be rubbed in at least 
twice every day, so long as any excoriated points appear after its appli- 
cation. Soap rubbed into the healthy skin will not be followed by 
such effects, the part feeling clean, smooth, and comfortable after it 
has been washed. The contrast this offers to the eczematous part is 
very striking, the latter presenting numerous intensely red, raw, and 
moist spots. The appearance of these red, shining, moist points after 
the first inunction suggests to the inexperienced eye that the malady 
has been aggravated ; but they become fewer in number after each 
application, and finally disappear, the eczematous surface being then no 
more affected by the soft soap than is the surrounding healthy skin. 

Many circumscribed patches of chronic eczema are greatly benefited 
by daily painting with a saturated solution of pyoktanin-blue. It is 
unproductive of pain in the majority of cases in which it is employed, 
and, as it forms a thin scale over the surface to which it is applied, prob- 
ably serves a good purpose for the time being by the exclusion of air. 
It acts also as a parasiticide. When the effect is markedly beneficial 
it leaves little to be desired in the way of local treatment. The chief 
objection to its employment lies in the staining it produces not only of 
the skin, but also of all articles brought into contact with it. 

Another valuable agent in the local treatment of these varieties of 
eczema is formalin, a solution representing 40 per cent, of formaldehyd. 
It is rarely tolerated by the skin in a strength greater than from 1 to 2 
per cent. 

Among the more severe measures occasionally employed for small 
patches of eczema which resist milder treatment may be named can- 

26 



402 INFLAMMATIONS. 

tharides employed as a blister, silver nitrate in crayon or in solution, 
from 3 to 60 grains to the ounce (0.20-4. to 30.), and iodine in combi- 
nation with carbolic acid. The following formula should furnish a 
clear vinous-red fluid, which may be applied pure or in dilution : 



M. 



In cases in which there is considerable pruritus, especially in obsti- 
nate patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for the above. The formula is : 

R Iodiniicryst.,1 --^ .. 4| 



R Iodin. tinct., 3ss; 


2 


Acid, carbolic, (cryst.), 3j ; 


4 


AlcohoHs' } ™ 5i { ; 


aa 8 


Aq. destillat., ad f^j; 


ad 30 


Sig. Iodized solution of carbolic acid. 





Acid, carbol. 
Combine with gentle heat and add an equal part of glycerin. 
Sig. Iodized phenol ; to be applied twice daily with a glass rod. 

Prognosis. — Eczema is an entirely curable disease, but uncertainty 
attends its prognosis as regards the duration of an attack and the prob- 
ability of the recurrence of a relapse. With respect to the questions 
most frequently asked, those relating to contagion, heredity, and 
persistent lesion-relics, a favorable response can be made; but the 
fact remains that some forms of the disease are insignificant, some 
persistent, and some particularly liable to relapse from very slight 
provocation. Only after careful weighing of all the conditions exhibited 
by the skin and by the other organs can a reasonable probability as to 
the future of the disease be estimated. Eczema is a disease exceedingly 
common, and one subject to aggravation by causes well-nigh innumera- 
ble. Were the physician always in position absolutely to insure his 
patient a proper mode of living, and the exclusion of all sources of 
irritation to the skin, the prognosis would be much more satisfactory. 
In hospital-patients, over whom such control is more perfectly attained, 
the results of treatment may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily relieved 
by proper treatment than are the chronic forms of the disease ; that 
eczema with a discoverable cause is more manageable than one the 
etiology of which is obscure ; that eczema of the very young and of 
the very old is at times particularly rebellious ; that the non-discharging 
phases of the disease are rather more persistent than those accompanied 
by secretion ; that eczema lingering at the mucous outlets of the body 
(auditory canal, nostrils, mouth, nipple, anus, vagina) is more obstinate 
than when it affects the skin of other parts (shoulder, neck, lumbar 
region) ; that eczema with constant aggravation or complications (fissure 
of skin of hand, varicose veins of leg, apparatus for anchylosis) is 
more stubborn in proportion as these complications or aggravations 
cannot, from the circumstances of each case, be set aside ; and, finally, 
that an eczema which has long existed, or has repeatedly recurred, as, 
for example, with every season of extremely cold or hot weather, is, 



ECZEMA. 403 

after relief, very liable to return. Eczema seborrhoicum (dermatitis 
seborrheica) affords brilliant results in all well-managed cases. The 
parasitic eczemas are also particularly amenable to treatment. 

Topical and Special Varieties of Eczema. 

Eczema of Children. — Inflammation of the skin in infants and 
young children is usually acute in type, owing to the delicate struct- 
ure of the skin and to the tendency in childhood to acute rather than 
subacute and chronic pathological changes in the various organs of the 
body; consequently the eczema of infants is commonly vesicular, 
pustular, or vesiculo-pustular in expression. Though acute in type, 
eczema of young children is frequently chronic in duration ; a child for 
example of two, three, or four years of age may have had the disease 
in varying degrees and extent since a few weeks after its birth. In 
these persistent cases there may be considerable thickening and infiltra- 
tion of the skin, and periods during which the symptoms are those 
of a subacute or chronic process ; but acute manifestations recur at 
frequent intervals and usually predominate. 

The causes peculiar to eczema of childhood are found in the ease and 
frequency with which the delicate skin is injured by external agents, 
such as soap, hard water, rough clothing, dirt, etc., together with the 
rubbing and scratching that follow pruritus from any cause ; in the 
presence of toxins in the blood, resulting from deficient elimination or 
from imperfect metabolism and assimilation of food, due commonly to 
improper or irregular feeding ; in the so-called reflex irritations arising 
from disorders of the alimentary tract, from dentition, and from other 
systemic disturbances ; and in the local infections of the skin with pus- 
cocci and probably at times with other micro-organisms. That local 
causes are responsible, at least in part, for many cases of infantile 
eczema may be readily inferred from the fact that the disease is com- 
monly limited to, or most severe in, those regions (the face, scalp, neck, 
ears, wrists, and hands) which are not protected by the clothing. In 
other instances the origin of the trouble can be directly traced to the 
irritation produced by some rough article of clothing, or to friction 
and secretion retained between two skin-surfaces, as in intertrigo. Con- 
stipation, overfeeding, or an improperly constituted diet are often the 
direct or indirect causes of eczema. Many fat infants affected with 
eczema improve rapidly after a mere reduction of the carbohydrates in 
their food. Rickets and other forms of malnutrition furnish a skin 
lacking in vitality, and therefore predispose to disease. Catarrh and 
other disorders of the gastro-intestinal tract are frequently accompanied 
by eczema, due, seemingly, to reflex irritation. In strumous children, 
adenopathy, furuncles, and conjunctivitis are frequent complications of 
eczema. Rhinitis or otorrhcea often produces a local inflammation of 
the skin, which may spread and persist as a pustular eczema. Sebor- 
rheal eczema occurs as in adults, but in children is more acute, and the 
moist types predominate. According to statistics gathered by Crocker, 
more than one-third of all cases of eczema in children begin during the 
first year of life. 



404 INFLAMMATIONS. 

Success in the treatment of these young patients depends, first, upon 
the painstaking search for, and removal of, the causes ; and secondly, 
upon the care with which the principles of treatment of acute eczema, 
already set forth, are carried out in all details. 

Eczema of the Scalp (Eczema Capitis, Eczema Capillitii). — 
When the scalp is affected with eczema the symptoms differ somewhat 
according to the age of the patient. In adults the erythematous and 
squamous varieties of the disease are more common ; in infants and 
children the pustular variety. In the former the eruption is usually 
circumscribed and in patches ; in the latter it is more diffused. In 
the same proportion, also, the former is generally asymmetrically and 
the latter symmetrically developed. 

In infants and children the pustules rupture early and their contents 
dry into dirty-whitish, yellowish, or greenish crusts, matting the hairs, 
thus serving as foci for dust-accumulation and as nests for lice, the 
crusts being superimposed upon a reddish, oozing, pus-covered, or 
occasionally indolent skin, often foul-smelling, and usually complicated 
by a seborrhoea. The so-called " milk-crust " is usually a compound 
of dried pus and altered sebum. The itching is not so intense as in 
some other forms of the disease. Post-cervical, pre-auricular, and 
occipital adenopathy are common, and in strumous children suppura- 
tion of the affected glands may occur, though this is rare. The causes 
of this form of disease are evidently associated with local conditions. 
The rapidly growing hairs of the scalp are in intimate association with 
the numerous and large sebaceous glands of the same part, which at 
times unquestionably respond by an exudative process to the physio- 
logical stimulus they feel. The acne of the young man whose beard is 
growing illustrates the same fact. Local irritants are not often wanting 
to push the disturbed equilibrium into the scale of disease. White 
calls attention to the common neglect in removing the " pre-natal cap 
of cheesy material/ 7 as well as to rude and unskilful attempts to accom- 
plish the same end. Extremes of temperature, friction, excess, neglect, 
and absence of endeavor to wash the scalp, all these contribute to orig- 
inate or to aggravate the disorder. 

The affection when complicated or induced by lice is more common 
in children than in infants, doubtless in consequence of the greater in- 
dependence of the former and their gregarious habits. In girls with 
relatively long hair the ova, or nits, of the parasite are readily distin- 
guished, adhering closely to the hairs and accumulated especially about 
the occipital region. The itching is usually more annoying than in 
pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhoea when scratching 
has been practised or irritant applications have been made. The erup- 
tion here usually occurs in asymmetrical patches, or it may be limited 
to a single patch tolerably well defined in outline, often upon one side 
of the scalp, not, as in infancy, preferring the vertex. Reference is 
made in the chapter on Seborrhoea to a form of eczema of the scalp oc- 
curring in adults in whom finger-nail-sized, circular, oozing or slightly 
crusted patches are generally disseminated over the affected surface. 



ECZEMA. 405 

They result, as a rule, from the scratching of au obstinate seborrhoea in 
"nervous" women. The reddish friable crusts indicate traumatism, 
the color being due to exuded blood. 

The diagnosis of these forms of disease has been already consid- 
ered. The disorders most commonly confused with eczema of the 
scalp are psoriasis, seborrhoea, tinea favosa, and tinea tonsurans. 

In the treatment of eczema of the scalp in infants and children 
the first indication to be met is the removal of the accumulated 
crusts. When this removal is harshly accomplished it becomes a 
fruitful source of further mischief; it is, therefore, necessary to pro- 
ceed with great gentleness. The thorough softening of the crusts 
is all-important. For this purpose it is necessary to soak them with 
oil and to retain this substance in intimate contact with the scalp. 
Olive- or cod-liver oil may be selected, and, if needful to correct the 
odor or for other purpose, 1 drachm (4.) of carbolic acid may be added 
to each pint (512.), with 2 drachms (8.) of the balsam of Peru. A 
neat-fitting skull-cap, constructed of Lister protective or of flannel, 
should then smoothly be applied, and fastened in place by a light band- 
age, never by elastic-rubber bands. After several hours of soaking 
the crusts should be removed with w T arm water and spirit-of-soap 
washing, and the entire process be repeated until the crusts are com- 
pletely detached. In selecting an article for subsequent medication 
of the scalp it should be remembered that even infantile eczema will 
proceed to a natural involution if unirritated ; hence oleated lime- 
water, or oil of sweet almonds alone, will often answer better than an 
ointment, and, even where there is considerable acuity of the inflam- 
matory process, lime-water alone, with possibly a small quantity of 
glycerin added, will be effective. In other cases lime-water can be 
medicated better with calomel or with zinc oxide. As the discharge 
and crusting cease ointments instead of oils and lotions may be 
employed. The ointment is to be gently rubbed over the surface with 
the tip of the finger, and the skin afterward protected with suitable 
dressing, such as a gauze-cap. Good ointment-bases for use on the 
scalp are lanolin, vaselin, equal parts of lanolin and oil, or equal 
parts of glycerin, lanolin, and oil. The following remedies may be 
incorporated in strength varying from 1 to 5 per cent. : carbolic, sali- 
cylic, and boric acids ; calomel, white precipitate, ichthvol, sulphur, 
resorcin, and tar. In children and in acute cases strong preparations 
must not be used. When the seborrhoeal element is at all pronounced 
the treatment is that of seborrhoeal eczema. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it is a more expeditious method of arriving at the 
end when a nurse has to dress the heads of several children in a 
single ward. Lice when present may be destroyed by the application 
of petroleum, bichloride lotions, or alcohol. The nits are removed 
with alcohol or with cologne-water from hairs which it is not desirable 
to cut. In adults, especially in women, the hair should be spared, 
while the patient is warned that the loss of the growth upon the scalp 
may be considerable. Where an obstinate seborrhoea is followed by 
eczema the latter may be succeeded by alopecia ; in the absence of 



406 INFLAMMATIONS. 

seborrhea the hairs usually are reproduced. It is rarely necessary to 
•employ the skull-cap in adults, since one can succeed in insuring the 
necessary applications by directing the attention of the patient to the 
necessity of care and thoroughness. 

As the disease in both classes of patients advances to a subacute or 
chronic stage the treatment may be made more stimulating. In the 
case of infants, however, stimulating topical remedies are very rarely 
to be employed. An eczema of the scalp that has once entered upon 
resolution, in an infant or a child, should generally be soothed and 
protected. 

Many children thus affected are in excellent general health, and 
require no internal medication. The prevailing tendency among the 
laity and even among many practitioners to dose these little ones with 
mercury, arsenic, iodides, and other " blood medicines " cannot be con- 
demned too severely. Frequently, however, the general health needs 
attention. Proper nourishment, elimination, and hygienic surroundings 
should be sought in every case. 

The treatment of erythematous and chronic eczema of the scalp in 
adults is described under eczema seborrhceicum. 

Eczema of the Face (Eczema Faciei). — Erythematous eczema 
of the face in adults is projected prominently among the varieties of the 
disease by its uniformity of type. It occurs in early and in middle 
life and in advanced years, and is a particularly intractable ailment. 
In well-marked cases the forehead, cheeks, eyelids, and nose of the 
patient are involved, exhibiting an infiltrated, usually dusky-red, often 
symmetrical patch of disease, the affected surface being slightly ele- 
vated above the level of the sound skin. This surface is uniformly 
smooth and reddened; occasionally, near the root of the nose and 
about the lower line of the forehead minute, closely set papules are 
visible. Very slight oozing, especially after irritation, may be noticed. 
At the height of the disease, or in its involution, exceedingly fine 
scales form, which are scarcely perceptibly shed from the surface. 
The eyelids, especially the lower lids in advanced years, become puffy. 
The line of demarcation of the attacked surface is unusually distinct, 
and rarely invades the scalp-border or the region of the beard. Itch- 
ing is at times intense, the patient bitterly complaining of it and 
usually preferring to rub the face with the hands or with pieces of 
cloth. Sometimes, however, the face is well scratched with the finger- 
nails and excoriations and blood-crusts disfigure the countenance. Pa- 
tients of intelligence usually describe the itching as paroxysmal and 
as starting at the root of the nose, whence it travels upward over the 
forehead and laterally to the brows, often in the line of the supraorbital 
nerves. At the root of the nose the exudative process is most marked. 
The eruption is seen also in asymmetrically disposed patches of various 
sizes, with islets of sound skin between. In typical cases the hairs of 
the eyebrow are reduced to a stubble by constant rubbing. In resolu- 
tion of the symmetrical form this condition of the eyebrows is com- 
monly observed. 

Patients thus affected are often those whose faces have especially 
been exposed to irritation, such as locomotive-engineers, pilots of sea- 



ECZEMA. 407 

going vessels, mechanics in trades in which the hands are soiled with 
irritants and afterward applied to the face, and women spending hours 
of each day over the laundry-tub or the kitchen-stove. In each class 
the operation of the cause is made manifest by the exacerbation of the 
disease after exposure. 

The affection is most commonly mistaken for erysipelas, a disorder 
from which it is readily differentiated by the chronicity of its course. 
The latter feature is particularly characteristic of this form of eczema, 
which is rarely completely relieved after the age of sixty within a 
twelve-month, and which, when it has existed for a long period of 
time, is particularly obstinate under the best treatment, recurring with 
exasperating frequency upon exposure of the face to atmospheric 
changes. The great vascularity, abundant supply of sensory nerves, 
and necessary exposure of the face explain this peculiarity. In its 
management the lotions and dusting-powders described under the treat- 
ment of acute eczema fulfil an important part. In some cases pastes, 
ointments, plasters, or the glycogelatins give better results than lotions 
and powders. Soothing applications should always be first employed ; 
and more stimulating applications may be tried later. In many cases 
Pick's " linimentum exsiccans M or traffacanth-fflycerin mucilage fur- 
nishes a pleasant and effective application. 

In obstinate cases tar and other stimulating remedies recommended 
for chronic eczema should be employed. It is well to remember in the 
management of any case that while a tarry application may be well 
tolerated over one part, as, for example, on the cheeks and near the 
nose, in another part, as, for example, over the eyelids, a zinc-salve 
may better be employed in the same individual. 

In patients of younger years and especially in infants the face is 
likely to display vesicular and pustular phases of the disease, forms 
more often of acute eczema, and correspondingly more manageable. 
The itching, and especially the burning sensations, are prone to be 
severe and crusts rapidly form. In infants the picture presented is 
often similar to that seen in the scalp, except that there are no hairs 
to be matted into crusts and there is often a reddish blush at the 
edge of the patch or where the crust has been removed, the redness of 
the oozing surface being somewhat more marked than the similar 
patches on the less vascular scalp. The scratching in these little 
patients is severe, crusts being torn off in part or wholly ; blood- 
crusted excoriations are common. In this way the area of surface 
involved is clearly extended, sleep is greatly disturbed, and the irrita- 
bility and fretfulness of the child bear heavily upon its general nutri- 
tion. In severe cases of long standing the mental tone of the little 
sufferers becomes singularly perverted and their character unquestion- 
ably changed. The eczema of the cheeks and chin of infants is often 
largely due to irritation reflected from eruption of the teeth. 

This chain of formidable symptoms well linked together will often 
bid defiance to the most skilled effort to impart ease to the tormented 
skin. In such cases the harness employed by White, of Boston, fills 
an important office : a skull-cap, made of firm old cotton or linen 
cloth, is closely fitted to the calvarium, and a mask of the same material 



408 INFLAMMATIONS. 

is shaped to the face with exactly placed apertures for the eyes, nose, 
mouth, and ears. This mask is gathered in beneath the chin, and laps 
over two inches at the back of the head ; it may be used only during 
sleep, or, in aggravated cases, also during the hours of wakefulness. A 
species of straight-jacket is made by passing the head of the child 
through a hole in the closed end of a small pillow-case, which is 
then drawn down over the body and arms, and the latter confined at 
the sides by stitching or pinning the case together between the trunk 
and the upper extremities. This jacket is finally secured by similar 
means between the thighs. When it is necessary to imprison the 
lower extremities they are similarly secured by pins within the pillow-- 
case ; and the outer edge of such trousers can be fastened to the bed 
or the cushion on which the child reclines. Of course, this treatment 
does not preclude the employment of the washes, ointments, etc., 
which are to be neatly applied next the skin beneath the "trousers" 
or the " jacket." The ointment or other application is thus retained 
in position, rest and protection from all external irritation are given 
to the tormented skin, and its natural tendency to repair soon brightens 
up the case. 

For the treatment of these cases are recommended the black wash 
and zinc-salve treatment, the diachylon salve, Lassar paste, boric acid 
ointment, lead lotions, glycerole of starch, and other preparations and 
methods described in full in the treatment of acute eczema. These 
cases are often very capricious in their course, and treatment may have 
to be changed frequently to meet the varying conditions. 

Eczema of the Lips (Eczema Labiorum). — Reference has already 
been made to the obstinacy of eczema occurring near the mucous out- 
lets of the body, a result due, probably, to the secretion furnished by 
the adjacent mucous tracts. The lips furnish an illustration alike of 
this pertinacity and aggravation. Their frequent motions in mastica- 
tion and articulation aggravate an eczema, which is, moreover, apt to 
be teased by a no less frequent thrusting out of the tongue (where there 
is no beard) to wet the parts with mucus and saliva. Vesicular, pus- 
tular, squamous, and erythematous lesions occur at one point, or along 
the entire line of the lip, with frequently resulting crusts and fissures. 
The vermilion border of the lips commonly participates in the process. 
The lips become hot, and sometimes much thickened by the swelling 
and infiltration, their mucous faces being rarely implicated. Scarlet, 
dull-red, and other peculiarly purplish hues of the vermilion border 
become visible. The parts are more picked than scratched, though 
the itching at times is severe. The pustular and vesicular forms are 
more common in children. The erythematous form, its reddened out- 
line roughened by scales evenly projected beyond the vermilion 
border, is rather an affection of maturer years. In many cases the 
disease is aggravated by nasal discharges which flow over the upper 
lip, giving the latter an elephantiasic aspect or even the appearance 
of an animaPs snout. In eczema of the hairy lip the symptoms and 
treatment are those of eczema barbae. 

The diagnosis is between hyphogenous sycosis, herpes labialis, epi- 
thelioma, and syphilis. The first is accompanied by loosening of the 



ECZEMA. 409 

hairs, caused by a vegetable parasite ; the second is vesicular in lesion, 
brief of duration, and trivial in severity ; the third is a disease of ad- 
vanced years rather than of early and middle life, and is accompanied 
by characteristic induration and ulceration and not by itching. Syphilis 
is fond of the angles of the lips ; in most cases, when thus limited, 
typical mucous patches of the mouth can be discovered. The lesions 
of syphilis at the angles of the mouth are seldom linear fissures, but 
are more often definitely outlined erosions, secreting a puriform mucus. 
Pustules and resulting crusts of the lips and the nose in female children 
are often eczematoid features due to the picking and scratching caused 
by lice upon the scalp. 

In male patients the pipe, the cigarette, and the cigar, as well as the 
tobacco chewed and expectorated, may aggravate the malady. In all 
cases it is obstinate and calls for either emollient, stimulant, or pro- 
tective applications. In eczema of the lips displaying acute and painful 
symptoms frequent fomentations of the part with soft rags dipped in 
hot mucilaginous and alkaline waters will aid in controlling the swell- 
ing and in alleviating the pain. After such bathing some soothing 
ointment should be applied. In chronic cases, in which stimulation is 
demanded, this can be effected at the time, of dressing, the parts being 
subsequently protected by collodion or other material. Carbolic acid 
and silver nitrate are often needed for such dressing. 

Equal parts of tincture of benzoin, alcohol, and glycerin applied 
frequently during the day is an excellent combination for the ver- 
milion border. For protecting this portion of the lip cold-cream or 
other simple salve to which has been added enough white wax to make 
as stiff an ointment as can be spread with the finger, is recommended. 
A drachm (4.) of the compound tincture of benzoin with 5 to 20 
(0.33-1.33) grains of tannin may often be added to such ointment with 
good results. 

Cheilitis Glandularis Aposthematosa, Myxadenitis Labi- 
ALis. — This is a rare form of chronic inflammation of the lips which 
might be confused with eczema of this region, and which has been 
described by Volkmann, 1 Purdon, 2 and Duhring. 3 

The disease consists in a firm swelling, usually of the lower lip, 
the mucous glands of which are congested and exude a muco-puruient 
secretion, which dries and forms crusts. There are few subjective 
sensations, but the condition is chronic and rebellious to treatment. 
Duhring states that the condition is usually associated with a depressed 
state of the nervous system. The treatment recommended consists in 
warm fomentations, simple lotions, and the occasional use of more 
stimulating preparations, such as alkalies and silver nitrate. 

Cheilitis Exfoliativa (Exfoliative Inflammation of the 
Lips). — This rare condition, which for convenience maybe classed with 
eczema of the lips, is described by Besnier, Galloway, Crocker, 4 Stel- 
wagon, 5 and others. In this disorder the lip is swollen, the vermilion 

1 Arch. f. path. Anat. u. Phvs., 1, p. 142. 

2 Brit. Jour. Derm., 1893, v., p. 23. 

3 Cutaneous Medicine, p. 403. 

4 Diseases of the Skin, p. 413. 

5 Jour. Cutau. Dis., 1900, xviii., p. 268. 



410 INFLAMMATIONS. 

border, and occasionally the adjacent skin and mucous membrane, are 
covered more or less with thin scales or more frequently with yellowish 
or brownish crusts which may be scanty, or abundant and very thick. 
The removal of the crusts shows the lip to be dry and the seat of 
numerous fissures and bleeding points. Rarely the surface is moist. 
The condition varies in intensity from time to time, but tends to persist 
indefinitely and is rebellious to treatment. It is seen most frequently 
on the lower lip, but occurs also on the upper. It is associated usually 
with seborrhoea of the face and scalp. Some form of indigestion has 
been present in most instances. 

The causes of the disease are not known, and the treatment is prac- 
tically that of eczema of the same region and is unsatisfactory. Stel- 
wagon and Jamieson found frequent painting with lactic acid of value. 

Labiomycosis. — Under this title Wilmott Evans 1 describes an 
eczematous condition of the lip involving a crescentic band one-quarter 
inch in width adjoining the vermilion border. In a series of these 
cases he found hyphomycetes, which he did not, however, succeed in 
cultivating. The cases all improved rapidly under ammoniated mer- 
cury ointment or other simple antiseptic applications. 

Eczema of the Nostrils (Eczema Narium). — Eczema of the nos- 
trils is naturally often associated with a chronic coryza. Inasmuch as 
one of the common symptoms of hereditary syphilis is the " snuffles," 
the physician should carefully exclude the possibility of such disorder 
in every instance when an infant with coryza exhibits an " eczema " 
of the nares or of the lips. The age of the little patient, an inspection 
of its anal region (which should never be omitted in infantile eczema), 
and the history of the case will throw considerable light upon this 
important question. 

Whether occurring in the adolescent or the child, the disease may 
linger only upon the alse in the pustular or the squamous form, or may 
block up the nares with crusts. In infants this obstruction enforces 
respiration with an open mouth, and the grasp of the nipple by the 
lips is thus interrupted either by respiratory acts or cries of agitation. 
The Schneiderian membrane participates in the inflammatory process 
and pours out its secretion upon the eczematous skin. This membrane 
when inspected is seen to be either raw and succulent, or in a condition 
analogous to that seen in pharyngitis sicca, is dry, glazed, and free 
from discharge. The nostrils are often thickened in consequence of 
infiltration or are fissured, especially at the lines of the nares, laterally 
and inferiorly. In severe cases, and when the lips participate in this 
process, the pouting, swollen, and distorted organs suggest the snout of 
the lower animals. Adults, as a result, frequently suffer from cocco- 
genous sycosis and furunculosis. 

Care should be taken to exclude syphilis in making a diagnosis, 
bearing in mind the fact that the pustular syphiloderm (which see) fre- 
quently selects the furrow on either side of the nostrils for its evolution. 

In treating these cases all crusts should be removed and the parts 
carefully be protected. Picking of the nose in children should be 
prevented, if needful, by the "straight-jacket." Pencillings with com- 
1 Brit. Jour. Derm., 1903, xv., p. 319. 



ECZEMA. 411 

pound tincture of benzoin, iodized phenol, silver nitrate, or collodion 
often prove serviceable. 

In softening crusts oil may be freely used. For this purpose the. 
warm carbolized oil-spray of the atomizer or a glycerin-lotion answers 
well. After softening and removal of the crusts a simple ointment 
containing from 5 to 20 grains (0.33-1.33) of boric acid, or from 2 to 
10 (0.13-0.66) grains of white precipitate to the ounce (30.) may be 
used. A weak citrine ointment is often serviceable. When the dis- 
ease extends well up the nares Neumann employs bougies made by 
combining 2 grains (0.133) of zinc oxide with 16 grains (1.06) of 
cocoa-butter. Hardaway recommends equal parts of cold-cream salve 
and glycerole of lead subacetate. 

Eczema of the Ears (Eczema Aurium). — The ears are affected 
with eczema, both in infancy and maturer years, rather more often in 
women and children, the disease being limited to the whole or part of 
the organ, or extending backward over the post-auricular region, or 
downward over the ramus of the superior maxilla. The eczema may 
be acute or be chronic, and commonly originates in seborrheic eczema 
(which see) of the scalp or the face, but may find its origin in chronic 
or catarrhal discharges from the external auditory meatus ; in the 
growth of aspergillus in the same canal ; in exposure to temperature- 
changes, especially with high winds ; in frostbite ; in the irritation set 
up by pediculi and by the auricular rim of the frame of spectacles ; in 
the toxic effect induced by the hook of cheap ear-rings and dyed bonnet 
ribbons ; in the traumatism of ear-piercing ; and in the habit of unnec- 
essarily picking the ear to relieve it of wax or of trifling sensations of 
irritation. 

The pustular and moist forms are common at the superior, inferior, 
and posterior boundaries of the pinna, where a linear fissure is liable to 
form in the line of the angle made by the auricle with the plane of the 
adjacent integument. The motions impressed upon the ear by handling 
it, or by placing the hat on the head and tying hat-strings over the ear, 
always tend to aggravate the disorder. Long hairs worn over the ears 
have a similar effect by the production of friction and the retention of 
heat. The lobules are likely to display the erythematous and scaly 
phases of eczema, becoming infiltrated, and having a deformed appear- 
ance and lurid-red color, the affection pursuing an indolent course. 
The lobules alone of both ears in young women may similarly be 
affected, and may exhibit these phenomena for consecutive years. Often 
the chronic inflammation lays the foundation for a keloid growth, an 
accident of inflammatory processes in other parts. 

Sometimes the entire auricles are uniformly dark red, infiltrated, 
alternately weeping and scaling, and project to a noticeable extent from 
the side of the head in consequence of their increase in bulk. The 
itching is usually more annoying than severe, being accompanied by a 
characteristic sensation of tenseness and fulness of the part. Like the 
eczema which occurs at the other mucous outlets of the body, the affec- 
tion in the meatus is particularly obstinate when it assumes a chronic 
form. Symmetry to the extent of involving both ears, though com- 
monly to a different degree in each, is rather the rule than the exception, 
and is doubtless due to the simultaneous operation of effective causes. 



412 INFLAMMATIONS. 

The diagnosis is between erysipelas, seborrhoea (which occasionally 
occurs in the concha of the auricle), erythema simplex and multiforme, 
and dermatitis calorica. 

The treatment should at first be soothing and protective by zinc salve 
or diachylon ointment or by soothing and astringent lotions ; afterward 
it should be stimulating. A firm bandaging of the ears to the head 
may be required to support them, to prevent irregular pressure (of the 
head upon the pillow), and to retain external medicaments. In chronic 
cases stimulant applications are often well tolerated, and sulphur, 
salicylic acid, ichthyol, and tar ointments here play an important 
part. Treatment appropriate to the otitis externa or the aspergillus 
may be required. Bulkley recommends a tannin ointment, 1 drachm 
(4.) of tannin to the ounce (30.), deeply and thoroughly passed into 
the meatus on a camel's-hair brush. French authors generally advise 
small tampons smeared with an ointment and left in the canal. 
Burnett employs 2 drachms (8.) of oil of tar to 1 ounce (30.) of al- 
cohol. Great benefit is derived from painting the indolent surfaces 
w T ith solutions of silver nitrate. The intractable forms almost invari- 
ably affect adults, in whom there is usually a history of improvement 
under treatment, followed by relapse due to exposure to wind, heat, 
cold, or other sources of irritation. Many cases require the treatment 
recommended for eczema seborrhceicum. 

Eczema of the Eyelids (Eczema Palpebrarum). — In eczema of 
the eyelids the free edges of the eyelid, or the skin over the orbital 
margin of the tarsal cartilage, may chiefly be affected ; and these parts, 
both in children and adults. When the free edge of the eyelid is in- 
volved there is present a species of coccogenous sycosis, the hair-folli- 
cles becoming inflamed and furnishing a purulent discharge which may 
agglutinate the eyelids. The latter are thickened and swollen, become 
the seat of a moderate itching, are picked rather than scratched, and 
exhibit minute crusts between, or glued to, the hairs. The disorder is 
often accompanied by a seborrhoea of the Meibomian follicles, and is 
described by oculists under the designation of " blepharitis " or " tinea 
tarsi." Inasmuch as the facial expression is characteristic when 
the eyelids are thus involved, patients exhibiting this form of eczema 
are usually set down as " scrofulous," though the disorder occurs in 
many individuals with no other sign of struma, and eczema surely is 
not such a sign. 

Fissures occasionally form at the commissure of the eyelids. The 
disorder may complicate eczema of other parts of the face. In erythe- 
matous eczema faciei of adults there is usually swelling with puffiness, 
especially of the lower eyelid. The conjunctiva may or may not be 
implicated. A chronic granular condition of the eyelids is not noted 
as frequently as might be suggested by a priori reasoning. 

The edges of the eyelids should carefully be cleansed with a weak 
alkaline solution and a soft camePs-hair brush whenever the eyelid is 
involved, and then as carefully be dried and anointed with cold-cream 
salve. In acute cases the closed eyelids may be bathed frequently 
with Avarm solutions of boric acid or of borax (1 to 2 drachms [4. to 
8.] to the pint), and strips of soft lint, soaked in the same solution, 






ECZEMA. 413 

or a very dilute glycerin and carbolic acid lotion may be laid over the 
closed lids for as long periods during the day as these remedies are 
comfortably tolerated. In chronic cases red mercuric oxide ointment, 
from 1 grain to 10 (0.066-0.66) to the ounce (30.), with or without an 
equal quantity of salicylic acid, is held in high esteem. Oculists, in 
the treatment of this affection, are fond of using an ointment of yellow 
mercuric oxide, 1 to 3 grains (0.066 to 0.2) to the drachm (4.). In 
place of these mercurials the unguentum hydrargyri nitratis, 1 part to 
6 of cold-cream salve, may be applied, or resorcin 1 part to 100 of 
simple unguent. Epilation of the eyelashes may be necessary. Pen- 
cillings with solutions of silver nitrate in various strengths are also 
useful in chronic cases, but these solutions must carefully be confined 
to the eyelids, and not be suffered to come in contact with the con- 
junctiva. Excessive use of the eyes must be prohibited. 

In the diagnosis care must be taken to exclude syphilis, lupus, and 
pediculi. Piedra of the eyelashes must not be overlooked. Instead 
of the ordinary nits of the lash, there are in such cases jet-black, pin- 
head-sized masses of ivory-like hardness attached to the hairs. 

Eczema of the Beard (Eczema Barbae). — Eczema may involve 
the region of the beard only, or it may exist in connection with the 
disease on other parts of the face. 

In recent cases there is no loss of hair, but in those of long standing 
the hairs are thinned and fail to hide completely the reddened surface 
beneath, covered here and there with pustules or displaying floors of 
broken pustules, dried inflammatory products, yellowish and greenish 
scales and crusts. Beneath the crusts the surface is smooth, not lumpy 
as in hyphogenous sycosis. The hair-follicles are not solely involved, 
as in the coccogenous form of that disease, but evidently they and also 
the integument between them are inflamed. In chronic cases the symp- 
toms may be those of erythematous and scaling eczema. In recent 
eczema the hairs are not loosened in their follicles, but in chronic cases 
such loosening does occur, and there is a true defluvium capillitii. 
The disorder is one primarily involving the skin, and secondarily the 
hair-follicle, extending smoothly over the surface, as smoothly as an 
eczema on the cheek of a woman. There is commonly a certain 
degree of symmetry, to the extent at least of involving the beard in 
different degrees on both cheeks at once, or the chin on both sides ; 
often the symmetry is perfect. This symmetry is rare in the several 
sycoses of the same part. 

The disease is accompanied by itching, rarely so severe as upon the 
smooth parts of the face, is particularly obstinate, and is extremely 
disfiguring. When extending into the region of the beard from other 
parts it is usually associated with eczema of the ears. When limited 
to the region of the moustache it may be connected with an eczema 
of the nares and a chronic nasal catarrh or be a symptom of seborrheic 
eczema. 

The condition is more superficial than that of hyphogenous sycosis 
and never shows any of the deep-seated nodules found in the latter 
disease. From coccogenous sycosis it is differentiated with greater dif- 
ficulty, as the two conditions have many features in common. Sycosis 



414 INFLAMMATIONS. 

is primarily an inflammation of the hair-follicles, a distinct folliculitis, 
and presents a characteristic pustule pierced by a hair at the mouth 
of the follicle. In this disease there are also found papules and small 
tubercles. Though there is a superficial inflammation of the follicle 
in eczema of the beard, a distinct folliculitis is not present and there 
are no papules or tubercles. Moreover, the skin-surface between the 
follicles is evenly involved in eczema, while it frequently escapes wholly 
or in part in sycosis. Eczema quite commonly coexists on other por- 
tions of the face, while sycosis is limited strictly to the region of the 
beard. 

The treatment of recent cases of eczema of the beard is that of sim- 
ilar phases of the disease on other parts of the body, by means of the 
simpler lotions and ointments, but cases of long standing are exceed- 
ingly stubborn and frequently require vigorous measures. After remov- 
ing crusts and other accumulations by soaking with oil and thorough 
washing with soap and water the beard must be wholly removed. 
Clipping short the hairs of the face will not answer, though this is 
generally preferred by the patient as exposing to a less degree the 
unsightly surface beneath. Nothing short of epilation or of shaving, 
and repeated shaving every second day, will effect the desired result 
in chronic cases. As soon as the disease is reduced practically to an 
eczema of the non-hairy parts it improves in proportion to its distance 
from the mucous outlets of the body. When limited to the bearded 
cheeks the most obstinate cases in the course of a single month may be 
robbed of one-half their unsightliness. The patient should be encour- 
aged by reminding him that usually it is but the first step which costs, 
each succeeding removal of the beard being accomplished with greater 
comfort to himself physically and mentally. After each shaving the 
skin should be bathed with water as hot as tolerable, and, if at night, a 
lotion or an ointment, or the latter after the former, may be used. The 
salves most useful for this purpose are sulphur, 10 to 60 grains to the 
ounce (0.66-4. to 30.); diachylon ointment with salicylic acid, 5 to 10 
grains to the ounce (0.33-0.66 to 30.), and zinc or tar ointment. 
Rarely, the surface requires painting with weak solutions of silver 
nitrate. As the condition improves a dusting-powder will afford 
needed protection during the day. The shaving should be continued 
for months after the disease is at an end. 

Eczema of the Genital Organs (Eczema Genitalium). — In 
eczema of the genital organs the disease is remarkable for the severity 
of the subjective sensations it occasions; for its tendency to persistence, 
recrudescence, and nocturnal exacerbation; and for the liability to the 
production of the sexual orgasm by the act of scratching. In men the 
surfaces most often involved are the anterior, the posterior, or lateral 
faces of the scrotum where they meet the thigh, though the surface of 
the penis, as also that of the pubes and the perineum, may be involved. 
In women the labia majora, more rarely the labia minora and vestibule 
of the vagina, are affected, with occasionally extension of the disease to 
the same contiguous parts as in men. 

Eczema thus located is, as a French writer has well said, "a dry 
disease in a moist locality," Vesicular and pustular forms are much 



ECZEMA. 415 

rarer than the erythematous, the papular, the papulosquamous, and 
the erythemato-squamous. In women the moister forms are more 
frequent, doubtless because of the wider mucous outlet and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, cedematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most of the 
severe cases. An eczema intertrigo at the labio-femoral angle is com- 
mon. Over the whole may be poured the normal or pathologically 
altered secretions from uterus or vagina. The disease, however, is suf- 
ficiently common after the menopause, when there is usually physio- 
logical atrophy of the uterus. 

The typical disease in men is recognized in the thickened, reddened, 
perhaps slightly scaling integument of the scrotum, which may also be 
fissured, excoriated by the finger-nails, or covered with blood-crusts. 
Torn papules, even tubercles and nodose swellings may be closely 
packed together, exhibiting a lurid or even purplish hue. In aggravated 
cases the infiltration is so great as to deform the parts, increasing the 
thickness and deepening the normal furrows of the scrotal integument 
to the grade of many times its normal dimensions, producing thus an 
elephantiasic appearance. In eczema of the penis also the prominent 
symptoms are oedema, itching, and redness with slight scaliness. 

In both sexes, as before indicated, attempts to relieve the itching are 
often as severe and prolonged as they are ingenious. Commonly no 
relief is obtained until a serous sweating or weeping of the thickened 
tissues is induced by the friction. Inasmuch as the latter in severe 
cases is frequently repeated, the physical dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are often 
registered by the physician. Though unconnected with venereal dis- 
ease of any kind, there is for many a special dread of an eczema of 
these parts simply because of its location. With sleep disturbed, the 
mind agitated, and the nervous system teased by an intolerable pru- 
ritus, one can scarcely wonder at the eloquence with which many 
patients describe their sufferings. It is a disease of middle life and of 
advanced years. It is rare to see a well-marked, obstinate case in a 
child. 

The causes, exciting and aggravating, of eczema of the genital region 
are often obscure, but undoubtedly depend largely upon heat, moisture, 
and friction. These factors are favored — first, by the effect of gravity, 
the organs in question being situated, when the body is in the erect 
position, at the inferior apex of the double cone forming the trunk and 
being thus subject to the force of gravity ; second, by the arrangement 
of the clothing in both sexes, by which heat and friction-effects are 
heightened ; third, by uncleanliness, the secretions and discharges from 
the adjacent mucous tracts being suffered to accumulate upon the person. 
The cause may lie in some disturbance of the genital organs or of the 
general nervous system. In some cases the disease is apparently reflex 
in origin. 

In many eczemas of the surface, and especially those of the genital 



416 INFLAMMATIONS. 

region, the urine will be found to contain albumin or sugar, and these 
conditions have been supposed to lie at the root of the eczema. The 
diet of the eczematous patient with saccharine urine is of prime impor- 
tance. In some cases, however, the eczema causes the elimination of the 
sugar or the albumin, and not the reverse. Sugar and albumin are 
known to be producible in urine by external irritants, among which are 
cutaneous diseases. Merely varnishing a portion of the skin has been 
followed by these effects. If a patient with saccharine urine and severe 
genital eczema can be kept in bed in the recumbent position for a few 
days, while any soothing application productive of comfort is continu- 
ously applied to the tender and excoriated surface, the sugar will often 
rapidly disappear from the urine. These renal symptoms are in part 
reflex, resulting from the extraordinary irritation of the nerves distrib- 
uted to the involved surfaces. Many cases of extensive and severe 
eczema of the genital region in both sexes occur in patients in whom 
careful and repeated examination of the urine fails to reveal sugar, 
but the practitioner is urged never to omit such examination in his 
treatment of a typical case. 

Patients exhibiting genital eczema with glycosuria may be separ- 
able into two distinct classes. The first and commoner class includes 
those patients presenting such marked physical symptoms that the urine 
may be suspected before chemical examination. These patients are 
extremely fleshy men or women given to an excessive consumption of 
beer. In such patients the sugar decreases pari passu with the eczema, 
if the beer is withheld and the local irritation is judiciously treated. 
In a second and much graver class of patients, chiefly women, there is 
a diabetic history (often also of pulmonary tuberculosis), and the gen- 
ital eczema is manifestly an epiphenomenon. These patients are rarely 
obese, usually the figure is that of a slender and delicate woman ; there 
is little, if any, use of alcoholic beverages and the local eczema is trifling 
in features as compared with that in the class first described. In these 
cases, too, under the influence of an appropriate dietary and local man- 
agement the genital eczema subsides, but the glycosuria persists often 
to a grave issue. Genital eczema occurring with glycosuria is one of a 
group of disorders named by French authors Diabetides Genitales. 

The diagnosis of eczema of the genital organs is between ringworm, 
acne, pruritus, pediculosis, the venereal disorders, and herpes progenita- 
lis. The first-named affection may occur alone or may induce or may 
be grafted upon the eczema. Ringworm may be recognized by the dis- 
covery of the microsporon or trichophyton, and is clinically distin- 
guished by the crescentic edge of the spreading patch, its convex border 
looking away from the genital centre. The " follicular vulvitis " of 
gynaecological authors is a genital acne and is manifestly limited to the 
glands and the periglandular tissues. The same is true of bromine and 
iodine acne, which may be developed in the same situation in both sexes. 
Genital pruritus may beget an eczema from scratching, but it is accom- 
panied primarily by no skin-lesion. The pubic louse is visible to the 
eye, as are also its reddish excreta and nits. The ulcers and sclerosis 
of chancroid and primary syphilis are rarely accompanied by pruritus, 
and, though occasionally multiple, never exhibit diffuse patches of dis- 



ECZEMA. 417 

ease. Syphilodermata are recognizable by their characteristic features 
and the history of an infectious disease. In herpes progenitalis there 
are precedent burning, smarting, or neuralgic sensations, the occurrence 
of vesicles or groups of vesicles (lesions rare in eczema of the genitals), 
and frequent limitation of the disorder to the mucous surfaces or to the 
muco-cutaneous lip by which such surfaces are bounded. In eczema 
these boundaries are usually respected and the disease is much more 
strictly cutaneous. 

The treatment is to be conducted on the general principles hereto- 
fore outlined. Sponging of the genital region with alkaline water 
as hot as can Avell be tolerated, followed by the blander lotions, oils, and 
ointments at night, and the use of antipruritic dusting-powders in the 
daytime, must not be omitted. One per cent, solutions of formalin are 
of value. In eczema of the scrotum a suspensory bandage lined with 
lint which is wet with a lotion, smeared with an ointment, or thoroughly 
covered with a powder, can usually be employed with advantage. 
The habit of scratching must be broken up at all hazards. In chronic 
cases treatment by soft soap and diachylon ointment will be found 
useful. Caustics, solutions of mercuric chloride and other mercurials, 
carbolic acid, and especially the tarry compounds, are often necessary. 
The Lassar paste also may be used w T ith advantage. In some persis- 
tent cases with decided infiltration, radiotherapy has given prompt relief. 

The following formulae are useful in allaying the irritation of some 
acute and subacute cases : 



R Liniment, calcis, f^iv; 120 

Belladonn. extr., gr. xij ; 

Zinci oxid., 3ij ; 8 

Glycerini, f gij ; 8 

Aq. calcis, f,liv; 120 



80 



M. 



Sig. Lotion to be applied at night after bathing the parts with hot water. 

R Liniment, calcis, f ^iv; 120 

Acid, hydrocyanic, dil., f 3j ; 4 

Liq. plumbi subacetat., f^ij; 8 

Glycerini, f 3ij ; 8 

Aq. ros., ad f^viij; 240 j M. 

Sig. Cream, for application on strips of old linen. 

Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated by 
intertrigo the latter condition requires special relief by the interposition 
of soft lint spread with an ointment. 

Eczema of the Anus and Anal Region (Eczema Ani). — Eczema 
of the anal region, in its etiology and characteristics, is closely allied 
to the same disease in the genital region. The presence of ascarides 
and hemorrhoids occasionally induces or aggravates the disorder ; 
though this complication is rarer than is commonly supposed. Multi- 
tudes of men and women who suffer from piles never complain of 
eczema. The eczema may occur in erythematous, squamous, or papu- 
lar form, in the order named ; thus exhibiting here, as in the genitals, 
"a dry disease in a moist locality." 

27 



418 INFLAMMATIONS. 

The redness, infiltration, and itching may be limited to the verge of 
the anus, radiate from the latter in stellate lines, creep upward between 
the nates in the cleft, sweep forward over the perineum to the genital 
region, or extend laterally with intermediate intertrigo over the inner 
face of each thigh. Rarely the buttocks are covered with the same 
lesions. Fissures are likely to form about the anal orifice. 

This disease is common in infancy, when want of care in the removal 
of the napkin is a fertile source of mischief ; and also in persons in mid- 
dle life and in advanced years, when it becomes particularly intractable. 
The itching is intense in the latter class, with frequent nocturnal exacer- 
bation. Unfortunately the scratching is often reflex, and is practised 
during sleep, from which the patient is often aroused by his or her 
manipulations. Pollutions fully recognized, or occurring during pro- 
found sleep, or, more usually, in states of semi-consciousness, compli- 
cate certain cases ; defecation becomes painful ; the harassed nervous 
system of the sufferer is often in a deplorably wretched condition. 
In cases of long standing the usual congested, thickened, infiltrated, 
and almost elephantiasic appearance of the skin is presented, with 
occasional fissures and exaggeration of the natural furrows. The part 
may simulate in aspect the formidable conditions discovered in passive 
pederasty. Excoriations are common around the anal verge. 

In the treatment of these cases the use of very hot water by 
sponging, and the subsequent application of ointments, in some 
cases mild but in others stimulating, have yielded the best results. 
In the case of infants dusting-powders and the blander ointments 
are alone to be employed ; in adults, especially in chronic cases, tar 
in some form is especially valuable. Here the Lassar paste may be 
applied or tincture of tar be freely painted over the surface, or there 
may be used one of the tarry ointments, such as the Wilkinson salve, 
of sufficient firmness to retain its form as an unguent when sub- 
jected to the heat of the part. Caustics, especially the silver nitrate 
in crayon, are useful when there are fissures. Corrosive sublimate, 
l to l of a grain (0.016-0.033) to 4 ounces (120.) of milk of almonds ; 
Squire's glycerole of plumbic subacetate, \ drachm (2.) in 2 ounces 
(60.) of glycerin and water, or, as a substitute for the latter, soft soap 
and diachylon plaster, are here of special service. Almond-oil, or an 
ointment containing 2 to 10 per cent, of carbolic acid, often gives 
relief. Duhring recommends the following: 

R 



Sulphur, prsecipitat., 


By; 


2 


\66 


Naphtol., 


9j; 


1 


33 


Morph. acet., 


gr- ij;J 




133 


Zinci carb., 


3j; 


4 




Ungt. aq. ros., 


3j; 


30 





M. 

When defecation is painful the stools should be semiliquid in order 
to insure non-aggravation of the local disorder, not, it need scarcely 
be remarked, with a view to eliminating any materies morbi by purga- 
tion. Small tampons of cotton may be smeared with an emollient oint- 
ment and gently be inserted for a short distance within the anus. 
Tincture of benzoin, 1 part to 8 of vaselin, may be used for this pur- 



ECZEMA. 419 

pose. Kaposi recommends cocoa-butter suppositories, containing zinc 
oxide with belladonna or opium. When complicated by true fissure 
of the anus the sphincter ani must be stretched or divided, or dilated 
with medicated bougies. At night a cataplasm is applied. The parts 
are washed frequently with tepid water, and the anal tampons are 
smeared with cocaine. During the day zinc oxide salve, 30 grains (2.) 
to the ounce (30.) of vaselin, is applied, and over this are thoroughly 
sprinkled equal parts of zinc oxide and bismuth subnitrate in fine 
powder. Collodion medicated with 1 to 3 per cent, of salicylic acid, 
and lotions containing 1 scruple (1.33) of silver nitrate to the ounce 
(30.), are of great value in many cases. Besnier recommends the use 
of a clyster after each bowel-movement, the fluid being retained for 
only a short time. Pencillings of fissures with crayon of silver nitrate 
are indispensable in severe cases. 

Veiel prefers the cautious use of chrysarobin to tar, employing the 
latter either in the form of spirits or as tar-diachylon, 1 part to 20, 
gradually increasing in strength. Carbolic acid, 1 to 5 per cent., and 
glycerin, 2 to 10 per cent., in elder-flower water or in almond-emulsion, 
are specially indicated in fleshy women when the disorder, as is often 
the case, is complicated with intertrigo. 

The key to most cases of anal eczema is to be sought in the dietary. 
This disorder, in adults particularly, is likely to be a significant symp- 
tom of gout, and without the dietetic and medicinal treatment of that 
condition no local applications avail. Tobacco and alcohol are invari- 
ably to be excluded in the case of patients of this class ; and blue pill, 
alkalies, colchicum, and salicylates are often needed. It is in these 
manifestations of eczema that health-resorts furnish their best results, 
necessitating and inviting, as they often do, an out-door life, an appro- 
priate regimen, and an avoidance of stimulants. Even in children and 
infants, when there are no ascarides in the rectum or the vulva, the 
dietetic management of the patient should never be neglected. 

Eczema of the Nipple and Breast of Women (Eczema Mamm^). 
— Eczema of the mammary region is common in nursing- women either 
from the irritation produced by the mouth of the infant, or, more 
commonly, in consequence of a galactorrhea. Eczema intertrigo is 
common below and between the breasts. The eczema here is vesicular, 
erythematous, or squamous in type, with fissures at the apex, the side, 
or the base of the nipple. The serous ooze from the infiltrated areas 
dries as usual into light-colored crusts. There are the characteristic 
burning and itching. The disease may occur on one or both breasts, and, 
especially with a galactorrhcea in the summer, may spread extensively, 
covering both breasts, the surface of the belly, and the intermammary 
region. The circumscribed forms occur also in pregnant or in unmarried 
women, and are to be distinguished from scabies, which in women is 
prone to occur upon the breast. 

Paget's Disease, which in its early stages presents all the appear- 
ances of an eczema, is more fully described in this treatise among the 
epitheliomata ; it is sufficient here to call attention to the important 
fact that a fairly well-defined eczematoid patch, surrounding the areola 
of the nipple or that organ only, with infiltration, itching, and possibly 



420 INFLAMMATIONS. 

a fissure of the nipple, or a crust covering a superficial erosion, may be 
the sign of an epitheliomatous change already advanced either in the 
affected part only or deeper in the galactiferous ducts of the breast itself. 
The treatment of mammary eczema is that of eczema in general. 
In severe cases with galactorrhcea nothing short of weaning the child 
and a cessation of all demands upon the breast will insure relief. Every 
effort should be made in milder cases to avoid this dernier ressort. The 
nipple should be thoroughly cleansed after each nursing. As a rule, 
hot water and soap may be used for the purpose without harm and 
usually with benefit. Any fissures existing should be then painted 
with compound tincture of benzoin, tincture of myrrh containing 1 
grain of mercuric chloride to each ounce (0.06 to 30.) or weak solutions 
(2-15 per cent.) of silver nitrate. The whole should immediately be 
covered with a protective ointment or paste. The zinc oxide or dia- 
chylon ointment spread on lint serves the purpose well. Salicylated 
and borated pastes are sometimes preferable. Lister's borax salve often 
does well : 



R Acid, boracic. subtil, pulv., ) -- -- -, 

^ ^ _ 1U aagr. xv; aa 1 

aa 3ss ; aa 2 



Cersealb., \ 

Paraffin., 

01. amygdal. 



M. 



In some instances stronger and more stimulating remedies are 
necessary. Before the child takes the breast all but the simplest 
preparations should be entirely removed with oil or other unirritating 
agent. 

Fournier recommends a breast-plate of caoutchouc. When the 
disease is limited to the nipple and areola in nursing-women the glass- 
and rubber-apparatus sold in the shops may be tried in the hope of 
saving the nipple from mouth-contacts in nursing. Sometimes they 
answer admirably ; often they utterly fail. Dusting-powders are valu- 
able in mild cases, and for any intertrigo that may exist between and 
beneath the breasts. 

Eczema of the Umbilicus (Eczema Umbilici). — This local variety 
of the disease is briefly described in the chapter devoted to Seborrhoea. 
In most cases it is either induced. or is aggravated by a seborrhoea fiuida 
which gives origin to the peculiarly nauseating odor characteristic of 
the disease. Generally a reddish and infiltrated, more or less annular 
patch surrounds the umbilical depression, which may be filled with 
crusts. Syphilodermata, pediculosis, and scabies in women are to be 
carefully excluded in the diagnosis. 

Liquor sodse chlorinate, carbolic acid solutions, and, in chronic cases, 
iodized phenol will be required in its management. The dressing of 
the navel in the newborn infant, the improperly adjusted apparatus 
for retention of an umbilical hernia, and the corsets or " uterine sup- 
porters " of women, should not be permitted to occasion or aggravate 
the disease. 

Anderson reports that in typical cases, especially of those affected 
with scabies, the navel is swollen and projects in the form of a small 
tumor. 



ECZEMA. 421 

Eczema Crurum (Eczema Crurale). — Upon the legs, where the 
force of gravity is more potent than in other parts of the body, aggra- 
vated forms of eczema are found complicated with varicose veins and 
oedema, with dense infiltrations and indurations. In ancient cases the 
frequent elephantiasic aspect is significant, one limb being several 
inches larger in circumference than its fellow. The skin is covered 
from knee to ankle with enormous patches of eczema rubrum of an in- 
tensely angry appearance, moist and crust-covered ; or is dry, glazed, 
and of a lurid, reddish hue ; or is dry, horny, and ridged with irregular 
projections surmounted by scales resembling the rough bark of a tree ; 
or, again, with or without oedema, the integument is tense, inelastic, 
seamed with scars of old varicose ulcers, and deeply and irregularly 
pigmented, a condition with some difficulty distinguished from syphi- 
litic ulceration of the same region. At its onset eczema of these parts 
may assume any one of its known forms. In infants in long clothing, 
where the lower extremities are subjected to a higher temperature than 
in adults, the vesioular and pustular forms are common. The exceed- 
ingly obstinate forms of eczema of the legs, especially those complicated 
with varicose veins, are, of course, chiefly encountered in middle life 
and in advanced years. 

The diagnosis is, in general, to be established by considering the 
points heretofore discussed. The chief difficulty lies in distinguishing 
the eczema associated with ancient varicose cicatrices of the leg from 
syphilitic scars of the same locality that have resulted from degener- 
ating tubercular syphilodermata or from gummata. In some cases, when 
no distinct history can be obtained, there will be a doubt, since the 
force of gravity upon the vessels, even without varicosities, produces 
certain common features, notably deep pigmentation, in both classes 
of cases. In women the sexual history is all-important, including the 
order of succession of abortions, miscarriages, and viable infants. In 
both sexes the discovery of other lesions, and especially of character- 
istic cicatrices elsewhere, must be attempted. It will be remembered 
that the syphilitic ulcer tends to the shape of a circle or a segment of 
a circle, and though occasionally existing as the sole lesion upon one 
leg, it is frequently multiple, or may involve both extremities, the pig- 
mentation in old cases occurring chiefly at the periphery of the scar. 
Very extensive pigmentation about ancient cicatrices, especially dis- 
posed between irregularly defined scars, is commoner in eczematous 
forms, as the pigmentation due to syphilis though long-lived is yet the 
more ephemeral. With periosteal nodes the diagnosis is clear. 

The treatment of eczema of the legs does not differ from that of 
eczema in general, except as regards the indications to be met rela- 
tive to the support of the parts, thus counteracting the effect of 
gravity. In severe cases rest with the foot elevated and the leg placed 
in the horizontal position should be maintained, and other indica- 
tions met by the use of the various liniments, lotions, and ointments 
already described. For those who must pursue their accustomed 
occupations the problem is difficult. An excellent preparation for 
subacute and chronic cases is found in the glycogelatins, as they 
furnish not only protection, but also some support. Moreover, they 



422 INFLAMMATIONS. 

frequently may be left in position for a week at a time. As a rule, 
they are not indicated in acute cases or where there is much discharge ; 
yet in some of these cases they are well tolerated and do good. A 
moderately firm paste is made by taking 30 parts each of white gelatin 
and zinc oxide, 40 parts of glycerin, and 90 parts of water. The 
method of preparation has been given in the preceding pages. From 
1 to 3 per cent, of ichthyol, thiol, or salicylic acid in most cases may 
be added with advantage. 

A dressing well adapted to the larger number of cases of eczema 
of the lower limbs is disinfection of the surface and the application of 
the Lassar paste or other well-selected unguent or paste, followed by 
dusting the whole area with a poAA'der, over which may be neatly 
applied, if desirable, a cheesecloth bandage. Often, however, this band- 
age may be dispensed with, as in both sexes a woman's long stock- 
ing, made light and thin, such as is used in the summer season and 
always of white or undyed cotton, may be drawn over the limb. 
Over this stocking may be wound, for the purpose of support, either 
a flannel bandage cut on the bias, which can, as a rule, be applied 
without especial skill by the inexpert, or in chronic cases that will 
tolerate it an elastic bandage, the inner white stocking being changed 
with each dressing. In the case of male patients it is often desirable 
that the man's " sock " be drawn over the long white stocking below. 
In this way support without compression (which is the essential point) 
may be secured. 

Excellent results may be obtained by the use of the pure rubber 
bandage, applied immediately next the skin, especially in cases compli- 
cated by oedema, ulceration, and venous varicosity. The method of its 
application is generally familiar to the profession. The starch bandage, 
the plaster-of-Paris dressing over folds of Canton flannel so arranged 
that it may be removed at will in the manner in which it is used by 
some surgeons in treatment of diseases of the joints, these and other 
immovable dressings may accomplish even more in obstinate cases than 
elastic apparatus. 

A favorite dressing in dry, papular, erythematous, and squamous 
patches of the disease is applied as follows : the parts are bathed 
with hot borated water for several minutes until the itching is relieved, 
and then are carefully and thoroughly dried. The patch is then com- 
pletely covered with a dusting-powder, which, according to the indica- 
tions of the case, is either emollient, astringent, or stimulating. Finely 
powdered tannin with French chalk, or boric acid and starch, or bis- 
muth subnitrate, zinc, and starch may thus be used. Strips of cheesecloth 
are superimposed. A snug-fitting rubber or flannel bandage cut on the 
bias encompasses the whole. The dressing is left in situ as long as it 
is comfortable, often for two or three days, when it can be removed. 
In properly selected cases the itching is relieved, the infiltration is 
reduced, and the patch soon loses its hypersemic aspect. Occasionally 
no other treatment will be required. 

Eczema of the Hands and the Feet (Eczema Manuum, Eczema 
Pedum). — No more striking illustration of the significance of the 
etiology of eczema can be adduced than that to be discovered in 



ECZEMA. 423 

the hands. With these organs man toils to earn his bread, and the 
eczema they display is their protest against the rude contacts which 
are thus necessitated. Unfortunately, in too many patients the 
imperative necessity of bread-winning forbids consent to the best 
methods of relief, viz., temporary disuse of these organs. The feet 
may be similarly attacked, and for similar reasons. All forms of eczema 
are here seen — erythematous, vesicular, papular, pustular, and squamous 
— -involving the entire surface, or being limited to the wrists, ankles, 
interdigital spaces, palmar or plantar surfaces, or one or more digits 
of either hand or foot. The motions of the part are so free that fis- 
sures are common and often are exceedingly painful. The itching may 
be severe, and parts of one hand or of one foot may be extensively 
rubbed, torn, or abraded by the other. Vesicles are frequently 
encountered upon delicate portions of the skin, as over the dorsum and 
interdigital spaces, while in the denser palm and sole such lesions are 
deep seated and do not tend to spontaneous rupture, but on puncture a 
clear serous or a cloudy fluid may be evacuated. 

Palmar and Plantar Eczema is commonly asymmetrical, but 
may be symmetrical. The hands are more often involved than the 
feet. The condition is characterized by the appearance of irregular, 
ill-defined, more or less diffuse areas of dry, dead-whitish, or hypersemic, 
indurated, and thickened integument, which may be fissured or which 
may produce such a tense inelasticity of the surface that the digits are 
semiflexed into the palm or sole. 

Circumscribed patches of eczema, with fairly defined outline, reddish 
in color beneath crust or scale, subacute in course, and accompanied by 
paroxysmal itching, are of common occurrence on the dorsum and also 
on the palm or the sole. In the latter situation they may be traversed 
by one or more painful fissures, the same being true of the fingers and 
the toes. Upon the back of the hand these circumscribed patches are 
prone to pursue an indolent course, improving temporarily under ap- 
propriate treatment and becoming aggravated by every exposure to 
the causes by which they were first induced. 

The long list of etiological factors which may here be efficient can 
scarcely be enumerated. The majority have already been considered 
in discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions, as well 
as the action of toxicants and dyes, must be remembered. Thus, 
printers, bakers, and masons suffer in the hands, and the wearers of 
dyed stockings and coarse, ill-fitting shoes and boots suffer in the feet. 
These so-called " Trade Eczemas" are often due wholly to local 
causes and disappear promptly on removal of the latter. Such con- 
ditions should properly be classed under chronic dermatitis. 

In the matter of diagnosis, it should be remembered that an eczema 
of the hands may follow a dermatitis due to the Rhus toxicodendron. 
In these cases the disease is found usually at the same time upon the 
face and in the genital or mammary regions. Scabies of the hand 
in America is rarer than eczema manuum. In scabies the vesicles 
are firmer, more often unruptured, are fewer, are more isolated, and 
more intermingled with crusts, pustules, and even with bullae, which 



424 INFLAMMATIONS. 

latter are rare in eczema. The discovery of the parasite or its bur- 
rows and a history of contagion will aid in removing doubt. Numer- 
ous pustular lesions in young subjects are, however, according to 
Hebra, most commonly produced by the acarus. The occurrence of 
the eruption on the body elsewhere than on the hand is also to be 
expected in scabies, with respect to which it should be remembered 
that the burrow may not be visible, and that it may be wanting when 
the parasites are present. Psoriasis of the palms and soles is almost 
always accompanied by the presence in other parts of the body of 
patches, the typical characters of which should throw light on the local 
disorder. They are dry, non-discharging lesions, very rarely fissured 
as is eczema of the hands, have a distinct contour (which is rare in 
eczema), and are covered with more abundant and more lustrous scales. 
Eczema is less sharply outlined, and occurs in larger and more diffused 
areas than either psoriasis or syphilis. The scaling syphilodermata 
of the palms and soles occur early and late in the disease, and usually 
after a distinct history of infection. The lesions in syphilis are usually 
isolated, firm, deep infiltrations, circular in outline, with very sharp 
definition, and they may be covered with dry, adherent, dirty-white 
scales, beneath which the brown-and-red hue of the persistent lesion 
can be discovered. Superficial or deep circular excavations of tissue, 
single or multiple, with punched or ragged edges, are visible. The 
eruption is rarely, like eczema, accompanied by itching or by dis- 
charge, but painful fissures may form. It occasionally affects the dor- 
sum of the hand or the foot, favorite sites of eczema manuum, but 
almost invariably it has in such cases swept thither from the palm or 
from the sole. 

In both syphilis and eczema of the hand the right organ in right- 
handed toilers is usually most involved, even where there is apparent 
symmetry of distribution of lesions. 

The treatment demands, first, rest for the organs and a simultaneous 
discontinuance of the exciting cause. In the trades the result of the 
latter can usually be demonstrated by the patient, who notices the dif- 
ference between the condition of the skin on Monday morning after a 
Sunday's rest and that which was distressing on the preceding Saturday 
night. When practicable, protection during labor must be secured by 
the use of gloves, neatly applied finger-cots, rubber-stalls, or bandages, 
retaining a dressing to the part of the hand or the foot that is the seat 
of the disease. For circumscribed, non-discharging patches on the 
dorsum of the hand or the foot the dressing described in connection 
with eczema of the extremities may be applied. When the nature 
of the labor performed is such as to render it impossible to secure 
protection of the hands or fingers in this way, something may be 
accomplished in a few cases by directing that the hand be frequently 
dipped in a protective solution or powdered during the hours of labor. 
Thus, printers may dust their fingers with lycopodium, and individuals 
compelled to retain their hands in irritating solutions can anoint these 
organs occasionally with an oily or fatty substance. Generally it may 
be said that an eczema of the hands is too frequently washed, and the 
ill effects of this practice are made evident not only in laundresses, 



ECZEMA. 425 

but also in mothers who personally attend to the dressing of young 
infants. After each washing, the hands should immediately be cov- 
ered with a suitable dressing, or Avith a simple lotion, ointment, or 
powder. For mild cases equal parts of tincture of benzoin, glycerin, 
and alcohol diluted more or less with water make a serviceable and 
agreeable application. For protection of the hands and for the reten- 
tion of dressings the cheap white cotton gloves such as are worn by 
infantrymen are convenient and serviceable. They should be large 
enough to go on over the dressings easily and should be washed as 
soon as soiled. When extensively and acutely involved the hand 
should carefully be dressed, each finger being separately wrapped in 
gauze which has been soaked in a lotion or oil or has been spread 
with the selected ointment or paste, and the whole covered with a 
bandage or other dressing. 

The local application must be chosen in accordance with the prin- 
ciples previously given for the treatment of eczema in general. In 
subacute and chronic types tarry compounds are very useful, and caus- 
tics more than ever needful when there are fissures. The fissures may 
often with advantage be painted with compound tincture of benzoin. 
Protective flexile collodion plays an admirable part about the finger- 
nails where irritable seams and fissures form with overhanging fringes 
of torn and ragged epidermis, bordered with red. In painful eczemas 
of this region the immersion, particularly at night, of the entire hand 
or the foot in hot borated water may be practised, followed by careful 
drying and dressing with the selected application. 

When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, with the aid of 
hot water, followed by a salicylated soap-plaster or by a salve contain- 
ing white precipitate, 10 to 20 grains to the ounce (0.66-1.33 to 30.), 
or some preparation of tar. For intractable cases caustic potash, in 
the strength of 20 to 30 per cent, solutions, can be mopped well into 
the thickened palm and be followed by a salve application. Radio- 
therapy has given us excellent results in a number of these cases, the 
technique being that employed in the treatment of psoriasis. Van 
Harlingen suggests : 



R 



Hydrarg. ammoniat., 


Bj; 


1 


Adipis, 


3ss; 


2 


Sevi benzoinat., 


Bvij ; 


10 


01. amygd. dulc, 


^x; 




Vaselin., 


ad 3vj ; 


ad 24 



33 



M. 

A paste useful in many mild cases and one which dries rapidly is 
made of 10 parts each of glycerin, dextrin, and water. To this may 
be added from 1 to 3 per cent, of thiol or ichthyol. The ingredients 
are mixed on a hot water-bath and form a sort of liniment, which may 
be painted on the skin. Unna's litharge-glycerin-starch paste, described 
on a preceding page, is also a valuable and effective preparation for sub- 
acute cases. For chronic, sluggish eczema of the palms Duhring recom- 
mends an ointment composed of equal parts of mercurous nitrate, 
plumbic acetate, and zinc oxide ointments. 



426 INFLAMMATIONS. 

For the fingers and hands Unna's mull-plasters, but only if freshly 
imported, fill every requirement. These plasters may be cut into 
strips and be applied with neatness to every digit. Zinc oxide, sali- 
cylic acid, tar, and ichthyol mulls are all available for this purpose. 

The condition known as Chapping of the hands and face is, prop- 
erly speaking, a dermatitis, since it is usually dependent upon exposure 
to wind and weather and disappears when the cause is removed. It 
sometimes occurs, however, as a condition indistinguishable clinically 
from mild eczema of this region. In those subject to this disorder care 
should be taken through the changeable weather of spring and autumn 
not to expose the skin to cold or wind, especially if the hands have 
been previously immersed in water and are not perfectly dry. In 
many instances the trouble can be prevented by a simple oiling of the 
skin after each washing, or instead of oil equal parts of tincture of 
benzoin, glycerin, and alcohol may be used. This last preparation is not 
only a preventive, but it often affords relief in mild cases. Severer forms 
should be treated as corresponding grades of dermatitis or of eczema. 

Eczema as it Affects the Nails (Eczema Unguium). — There is 
nothing characteristic of eczema in its effects upon the nails. These 
horny plates participate in the diseases which affect their matrices, and 
thus exhibit nutritional changes. There is, therefore, no eczema of the 
nail proper, but only an eczema of the digit by which the nail is affected. 
In well-marked cases, one, several, or all the nails of either hands or 
feet may lose their polish, or may become rough, punctate, furrowed 
laterally, and clubbed, or may present an appearance suggestive of 
worm-eaten surfaces. They lose their uniformly smooth attachment 
beneath and become tilted on their beds, with marked friability of their 
tissue. An eczematous condition of the skin at the nail-margin may 
be detected, where the usual redness, infiltration, and scaling, with a 
sensation of itching, point to the nature of the trouble. Rarely the nails 
are shed. The most misshapen will be succeeded by smooth and nat- 
ural growths of nail-substance if the disease of the matrix be completely 
relieved. The treatment, therefore, is the treatment of the cutaneous 
disease. Care must be taken to exclude psoriasis (to be generally 
recognized by lesions in other regions of the body), as also ringworm 
and favus of the nails, which end can be reached by microscopically 
examining scales scraped from the nail-surface. 

The finger-tips may be held in hot water for fifteen or twenty min- 
utes at night and the nails then shampooed as vigorously as the condi- 
tion will permit. A soft ointment should then be applied on lint or 
other material. Zinc oxide, white precipitate, salicylic acid, and tar 
salve will be found most effective for the larger number of cases. 
Often the organs may with advantage be protected during the daytime 
by the glycogelatins, powders, gloves, or by rubber-cots. 

Universal Eczema. — In these cases patients should be treated in 
bed. The diet, which is of great importance, should be of unstimulat- 
ing quality ; but it is not to be forgotten that in a disease involving 
the entire surface of the body the strength is sooner or later liable to 
be exhausted, and a supporting dietary, even ferruginous tonics, is often 
required. 



ECZEMA. 427 

The local treatment is by alkaline and bran-baths, followed by 
lime-Avater-and-oil lotions, a dusting-powder, ointment, or other dress- 
ing suited to the local condition. In treating universal eczema the 
entire surface does not usually require the same topical agents. Often 
there should be cold-cream salve, freshly made, for the eyelids; a 
dusting-powder for the non-discharging or scaling surface ; a salve or 
an oleated lotion for discharging surfaces of the integument; and 
special dressings for the extremities, the ears, the hands, etc. 

Eczema of the Tropics (Prickly Heat). 
(Eczema Solare, Lichen Tropicus, Miliaria Rubra, etc.) 

Under these titles has been described a number of disorders, some 
of which are more closely related to the forms of sudamen considered 
in connection with the functional derangements of the sweat-apparatus, 
others of which are instances of papular eczema, associated or not with 
profuse sweating under the influence of severe physical exertion or of 
high temperatures (solar heat). This disease is aggravated by all exter- 
nal and internal sources of irritation, including indigestion, the use of 
alcoholic beverages, of opiates, of flannel and of chemically dyed gar- 
ments worn next the skin, undue exertion in a heated medium, fatigue, 
and obesity. 

Etiology. — The disease is more common in those subjected to rapid 
and intense fluctuations in the temperature of the atmosphere than in 
those long accustomed to a relatively hot climate. It is thus exceed- 
ingly common in the northern and central parts of the United States, 
where sudden changes in temperature are frequent and of wide range 
in degree. It attacks alike individuals of both sexes and all ages, being 
often particularly severe in the obese and in infants, whose delicate skins 
no less than their bowels resent sudden and severe thermal changes. It, 
moreover, affects equally the vigorous and the debilitated. It is un- 
questionably seen in the severest grade among fleshy Europeans and in 
Americans emigrating to tropical climates who are habitually ingesting 
alcoholic beverages in excess. 

The disease is characterized by the occurrence of pin-point to pin- 
head-sized vesicles, bright-red papules, vesico-papules, or the two as 
coincident and commingled symptoms. The lesions are exceedingly 
numerous, and may in severe cases cover almost the entire so-called 
" non-hairy " surface of the body, though they are commonly much 
more limited in their diffusion. They are usually acuminate and dis- 
crete, though often thickly set together. They are of rapid occurrence, 
but in consequence of persistence of the cause may be slow to disap- 
pear or may repeatedly recur. The affected region is the seat of charac- 
teristic sensations of tingling, pricking, and burning. The attack may 
last for but a few days or be severe for a week or more. 

Treatment. — The local treatment of prickly heat is, in brief, that 
of the corresponding stage of eczema. Unguents are generally to be 
avoided, as the skin rarely tolerates them, and the same may be said 
of plasters and very cold baths. Baths or lotions (tepid, warm, to 



428 INFLAMMATIONS. 

moderately cool, as the feelings of the patient may decide to be most 
grateful), medicated with alkalies, bran, gelatin, or starch, will be found 
useful. After each application the skin is to be dried by gently pressing 
dry towels over the surface, not by rubbing, and is then to be thoroughly 
protected by a free use of one of the dusting-powders, particularly boric 
acid and talc, or one of the zinc stearate preparations. When large 
tracts of the skin are involved, and general baths have been ordered, 
starch in fine powder will often be found well suited for topical em- 
ployment. 

Lotions may also be employed, composed of lead, or of lead and 
opium, or black wash, or alcoholic and ethereal solutions containing 
camphor and glycerin in the proportions given when considering the 
subject of acute eczema. Modifications of oleated lime-water are 
serviceable in severe cases, as, for example : 

B 01. lini, fSiJ; 60 

LTon.^til., } -SU; -60 



01. bergamii, q. s. ; q. s 

Aq. calcis, ad Oj ; ad 500 

Sig. For external use. 



M. 



This preparation makes a demulcent creamy solution which often 
proves grateful to the skin ; to it may be added zinc oxide or carbolic 
or dilute hydrocyanic acid, as required. 

The general treatment of the patient is a matter of importance. The 
cause must be removed if possible. Withdrawal from the light, heat, 
and labor of the day, the use of unstimulating food and drink, unirri- 
tating apparel, and rest are of great importance. Saline and acidu- 
lated beverages are usually acceptable to the palate, and useful if not 
drunk too cold. The free use of lemonade, Vichy, Kissengen, Apolli- 
naris, or other pure water, carbonated or aerated, is useful in aiding 
elimination and in supplying the fluids demanded by the cutaneous 
loss through evaporation. 

Prognosis. — The disorder may be trivial or be severe, and may 
last but for a few hours or for several months. It is usually relieved 
without difficulty, often by domestic measures alone. 



ECZEMA SEBORRHOEICUM. 

(Dermatitis Seborrhceica.) 

Duhring was the first observer to show that a type of inflammation 
of the skin, to which he gave the name seborrhoea corporis, was closely 
allied to, and usually consecutive to, seborrhoea capitis. Later, Unna 1 
advanced the theory that a single morbid process, to which he gave the 
name eczema seborrheic um, is responsible for a number of varied clin- 
ical manifestations which had previously been considered separate dis- 
orders. Under this title he includes seborrhoea sicca (or pityriasis) of 
the scalp, face, and body, some chronic circumscribed forms of eczema, 
and many cases which most observers still believe are forms of psoriasis. 

1 Monatshefte, 1887, vii. ; and Histopathology. 



ECZEMA. 429 

Though Unna gives to eczema seborrhoeicum a wider range than is 
accepted by the majority of dermatologists, there is little doubt that 
most of the phenomena he describes under this title are intimately 
related etiologically and pathologically. In America Elliott has fur- 
nished an excellent presentation of the subject. 1 In the following 
description the writings of both observers have been freely consulted. 

Symptoms. — Eczema seborrhoeicum almost invariably begins on 
the scalp and often remains limited to this region, though frequently 
it extends to the ears, temples, forehead, neck, and adjacent parts. 
The disease is not uncommon on other parts of the body where the 
sebaceous glands are large and abundant, as in the sternal, interscapular, 
inguino-scrotal, axillary, and umbilical regions. It may appear, how- 
ever, on any part of the body and in rare instances is universal. The 
disease is extremely variable in its course and mode of extension. It 
may remain confined to the scalp for years and then extend to adjacent 
surfaces, or appear on portions of the body distant from the scalp, 
leaving the intervening surfaces unaffected. Such spreading of the 
disease may be very rapid, or so slow as to be almost inappreciable, 
while the lesions may be numerous, extensive, and acute in type, or 
few, scattered, and indolent in character. 

The affection varies considerably in appearance in its different phases 
and especially in different regions. In the scaly form, which is the 
most common, there may be simply a scanty or abundant formation of 
fine branny scales with apparently little other change from the normal, 
though the skin may be slightly reddened, and often has the peculiar 
yellowish color which is characteristic of the disease. The scales may 
be large and abundant, and heaped up in dry, adherent masses, simu- 
lating those sometimes seen in psoriasis, but in such cases the scales 
are usually somewhat fatty. Frequently there is a coexisting seborrhcea 
oleosa, with the formation of yellowish to brownish, soft, greasy, and 
non-adherent masses, suggesting crusts rather than scales, under which 
the skin is more or less reddened and the mouths of the follicles 
patulous. 

The disease often appears in the form of oval or rounded macules 
and patches, or as small scale-capped papules which may remain dis- 
crete or may coalesce to form slightly elevated plaques. The macules, 
papules, and plaques are sharply outlined, and patches that are spread- 
ing peripherally frequently present a circinate border with a fading 
yellowish centre. By the coalescence of several such areas poly cyclic, 
gyrate bands may be produced. The color of the lesions is reddish or 
pinkish, modified by the yellow tinge that is nearly always present. 
Scaling and crusting in varying degrees are usually present as in the 
more diffuse forms described above. The lesions may occasionally be 
moist over all or parts of their surfaces, but the characteristic vesicles 
and pustules of eczema are absent and the discharge when present is 
usually distinctly greasy. A transformation to the ordinary forms of 
moist eczema may occur in which the characters, both clinical and his- 
tological, of the original eczema seborrhoeicum are lost. Of the varied 
manifestations of the disease the scaling forms are the most common 
1 Morrow's System, iii., p. 273. 



430 INFLAMMATIONS. 

but in a given case the type may change gradually or rapidly, and 
multiformity of lesions is not unusual. Itching is usually slight and 
may be absent. 

On the scalp the onset of the disorder is particularly insidious and 
often unnoticed until attention is attracted to it by a thinning of the 
hair, moderate or really annoying pruritus, and a scanty or abundant 
formation of scales over more or less of the scalp. In the early and 
mild forms the condition is practically that described under seborrhoea 
sicca. The vertex is the usual site of the affection, but the entire 
scalp may be involved. The scales may appear in any of the forms 
described above, but are usually fine, dry, grayish, and slightly greasy. 
The lowest layers of the scales are usually firmly attached to the 
underlying surface, which is commonly dry, lustreless, and pale, though 
it may be slightly hypersemic. After the condition has existed for a 
time alopecia is noticed, while the hairs of the affected regions are dry 
and lustreless. The condition may persist for months or years with 
but slight change. In more severe forms the heavier masses of scales 
and crusts described above may form upon distinctly reddened or moist 
patches. Seborrhoea oleosa may complicate the process with its char- 
acteristic greasy crusts and oily condition of scalp and hair. In infants 
and occasionally in adults an acute dermatitis may supervene, involving 
portions or all the scalp and usually extending to the adjacent portions 
of the. face. The conditions known as Milk-crust (described under 
Seborrhoea) may well be considered a form of dermatitis seborrhoei'ca. 
In adults circumscribed, oval or circinate, reddened, and scaling, moist 
or crusted patches may appear, chiefly about the temporal and parietal 
regions, often extending to the ears and portions of the face. Occa- 
sionally a sharply defined red band, more or less covered with scales or 
small crusts, may be seen at the margin of the hair, especially on the 
forehead and on the neck. Such bands closely resemble those of psori- 
asis, but usually have a more regular and even outline, much less infil- 
tration and thickening of the skin, and lack the characteristic scales 
and outlying separate lesions of psoriasis. 

The ears and the surfaces surrounding them are, after the scalp, 
more frequently involved than other parts of the body. Any of the 
above-described types of the disease may be seen in this region, the 
moist and crusting forms being quite common, especially back of the 
ears, where fissures frequently occur. The disorder not rarely affects 
to a very marked degree the lining of the external conduit of the ear, 
blocking it with crusts and interfering seriously with audition. 

The beard, moustache, eyebrows, and pubes may present symptoms 
differing but slightly from those in the scalp. The disorder may linger 
about the verge of the moustache or other parts of the beard, showing 
its grease and scales even at a distance from the line of hairs, with a 
well-defined reddened surface beneath. The same occurs about the 
line of the eyebrows. Alopecia is uncommon in any of the regions 
except the eyebrows. 

On the face the pityriasic forms are common on the nose and 
adjoining portions of the cheeks, the eyebrows and the region between, 
the eyelids and their margins, and may be exhibited on any part of the 



ECZEMA. 431 

face. Loss of hair from the eyebrows and eyelids is not unusual (see 
Seborrhoea sicca). The more inflammatory moist and crusting types 
are most frequent along the junction of the ala3 of the nose with the 
cheeks, but may involve the entire nose and other parts of the face. 
The macular and papular types, above described, are most common on 
the cheeks. 

Seborrhea Corporis, Seborrhcea Papulosa or Lichenoides 
(Crocker), Lichen Circumscriptus (Willan), Lichen Annulatus 
et Serpiginosus (Wilson), Flannel-rash. — Upon the trunk is 
frequently found Unna's " flower-leaf" or "petaloid" type of the 
eruption which was first described by Duhring and to w r hich have 
been assigned by diiferent authors the titles here enumerated. Its 
favorite sites are the sternum and interscapular region, but rarely it 
spreads in more extensive areas on other parts of the trunk. In a 
well-marked case the lesions appear in the form of sharply outlined 
circles or segments of circles which enlarge centrifiigally, often coalesc- 
ing to form patches with irregularly circinate outlines. The extreme 
borders, which represent the early stage of the lesions, are made up of 
very small red papules, usually covered with fine whitish or yellowish, 
dry or fatty scales. As the border progresses the centre undergoes 
involution, so that from without inward the patch may display varying 
shades of red, brown, and yellow, while the whole surface is often the 
seat of a furfuraceous desquamation. Round or oval, somewhat ele- 
vated, solid lesions are frequent, and may scale slightly or be covered 
with yellow, greasy crusts. In less perfectly developed cases and in 
those modified with friction of the clothing or frequent bathing there 
may be simply yellowish, finely scaling patches with slightly reddened, 
more or less irregular borders. 

The eruption also occurs upon the trunk and extremities in the form 
of macules, papules, and reddened patches which by coalescence of 
individual lesions may become quite large. These lesions may present 
any degree of scaling or crusting, though there is usually a narrow 
uncovered reddened margin. The affected areas may be dry ; and in 
form, distribution, and general appearance closely simulate psoriasis ; 
or they may be somewhat moist and, as a result of irritation or of 
excessive exudation, may undergo a transformation to a condition indis- 
tinguishable from that of eczema. In most cases the yellowish color 
of the lesions is conspicuous, being most marked when the eruption is 
fading. 

In the axilla and groin the eruption often begins as an erythema 
intertrigo, and owing to the influence of heat, moisture, and friction 
in these regions secreting patches are common. From these points 
the disease often spreads to the adjoining surfaces, the advancing 
margin of the eruption always being sharply outlined and usually of 
circinate contour. 

The dorsal surface of the hands and fingers may be involved, and 
also the palms, on which pea-sized and larger ill-defined scale-covered 
macules are irregularly distributed over the surface. 

Etiology. — In his first description of eczema seborrhoeicum Unna 
claimed for it a parasitic origin. He has described three varieties of 



432 INFLAMMATIONS. 

diplococci which he found in the lesions of this disease, beside several 
varieties of bacilli which were occasionally present. Of these he con- 
sidered a mulberry-shaped coccus, which he called the morococcus, of 
special importance, and on occasions has produced with it, by the 
inoculation of pure cultures, one or more vesicles, but without repro- 
duction of a patch of true eczema seborrhoeicum. He also found 
Melassez's flask-shaped bacillus in the scales. 

Elliott 1 reports on a bacteriological study by W. H. Merrill, of fifty 
cases of eczema seborrhoeicum. In all but two cases, on which a solu- 
tion of resorcin had been freely used, bacteria of some kind were found. 
Merrill describes two varieties of diplococci and a bacillus, all three of 
which were present in thirty-one cases, while one or two of them were 
found in most of the remaining cases. Twelve inoculation-experiments 
were made, of which seven were successful; from pure cultures of the 
cocci typical lesions of the disease were produced, from which, in each 
case, the special coccus was recovered and cultivated. One of these 
cocci w r as decided to be chromogenic and the cause of the yellowish 
color characteristic of the disease. These experiments, though too few 
in number to be conclusive, would seem, when considered in connection 
with clinical evidence, to leave little doubt of the parasitic origin of the 
disease. The etiological value of the micro-bacillus of Unna and 
Sabouraud is considered in the discussion of seborrhoea. Positive 
evidence of the transmission of the disease from one individual to 
another is difficult to gqt, though a history of probable contagion is 
obtained frequently. 

Locally, heat, moisture, friction, and other forms of irritation may 
act as predisposing causes and favor the origin and spread of the dis- 
ease. On the body it is often found in those who perspire freely and 
who wear woollen next the skin. On the scalp it is common in 
those who keep the head covered much of the time. Elliott reports 
that most of his cases occurred in people who lived for the most 
part indoors, and that the affection is unusual on those who live 
largely in the open air. His explanation of the greater prevalence 
of the disease in winter than in summer is that in the former season 
most people live indoors, with poorer ventilation, and bathe less than 
in summer. 

The systemic conditions favoring the development of the disease are 
practically those named as predisposing causes of seborrhoea. 

Pathology. — Even in the mildest grades of the affection, corre- 
sponding to the condition known as pityriasis capitis, Elliot 2 found 
" slight inflammatory infiltration about the papillary vessels and the 
ascending branches from the subpapillary plexus, and along the 
hair- follicles," while in the rete there were some vacuole-like forma- 
tions in the basal layer, and a few wandering cells. In severer 
grades the inflammatory infiltration extended to the subpapillary 
plexus, and in higher grades to the entire cutis, which was then 
somewhat oedematous. In the rete, vacuoles were numerous and their 

1 N. Y. Med. Jour., 1895, Ixii., p. 528. A subsequent report by Merrill, Ibid., 1897, 
lxv., p. 322, confirms these findings. 

2 Morrow's System, iii., p. 282. 



ECZEMA. 433 

origin could be traced to a nuclear degeneration. Many wandering 
cells were present, also karyokinetic figures and areas of cell-degen- 
eration. The horny layer was thickened and easily detached from 
the interfollicular spaces, but densely packed in the dilated open- 
ings and necks of the follicles. The sebaceous glands were appar- 
ently normal. The coil-glands in many instances were dilated and 
contained cast-off epithelial cells mixed with a granular debris, 
while mitosis and cell-degeneration were seen frequently. Elliot 
found no appearance that would warrant him in believing the coil- 
glands to be the source of the fatty hypersecretion. Unna, on the 
other hand, found fat in the coil-glands, and believes them to be the 
source of most of the fatty secretion characteristic of the disease. He 
also describes an infiltration of small, free globules of fat through all 
parts of the cutis and rete, inside the lymph-sacs. Elliot found no 
evidences of such infiltration ; but Ledermann announces that he has 
recognized it in normal epithelium. 

Unna and Elliot agree in considering all stages of the process an 
inflammation of a catarrhal nature, the immediate cause of which is 
to be found in one or more specific micro-organisms. (See also 
Seborrhoea). 

Diagnosis. — From other forms of dermatitis and from simple 
eczema, eczema seborrhoicum may be distinguished by its origin on 
the scalp, its oily secretion and crusts, the yellowish color and sharp 
outline of its lesions, its tendency to spread peripherally in circinate 
outlines, and by its lack of marked subjective sensations. 

In some forms of the disease the diagnosis from psoriasis is diffi- 
cult, but the location of the lesions on the flexor rather than on the 
extensor surfaces, the oily character of the scales and crusts, the yellow- 
ish color, the greasy and scaly centre of circinate lesions undergoing 
involution, and the general course of the eruption, will usually suffice 
to distinguish the disease. 

Pityriasis rosea may present appearances identical with those of 
eczema seborrhoeicum of the trunk and extremities. The lesions in 
the former disease, however, do not appear on the scalp, usually have 
ill-defined, frayed-out borders, and the enlarging rings present a dry, 
fawn-colored centre which is free from greasy scales. The affection, 
moreover, runs an acute course, rarely lasting more than six or eight 
weeks. 

Treatment. — Sulphur, resorcin, salicylic acid, white precipitate, and 
other preparations of mercury are remedies most useful in the treatment 
of all stages of the disease. For the earlier and dry forms, stronger 
and more stimulating preparations may be used, together with more fre- 
quent washings of the skin, than in the acute, moist forms, which must 
be treated more in accordance with the principles laid down for the 
treatment of the corresponding stages of eczema. For the scalp and 
other hairy portions of the body lotions are usually better than oint- 
ments. The lotion recommended by Elliott, containing 3 to 20 per 
cent, of resorcin in equal parts of alcohol and water, is one of the best, 
and should be applied two or three times daily. For the dry forms 
of the disease a small amount of oil — preferably the oil of sweet 

23 



434 INFLAMMATIONS. 

almonds — to prevent the disagreeable drying effect of the lotion 
alone, may be added. Instead of thus combining the oil with the 
liquid, a thin ointment containing resorcin or sulphur may be 
substituted for or applied after the lotion. After soap-and-water 
washings, which should be used often enough to prevent accu- 
mulation of scales and crusts, an oily or fatty application is always 
desirable. 

The most serviceable ointment in the majority of cases is one con- 
taining from 1 scruple to 2 drachms (1.33 to 8.) of sublimated or 
precipitated sulphur, 10 minims (0.66) of balsam of Peru, and 1 ounce 
(30.) of vaselin. Instead of sulphur, resorcin or white precipitate may 
be used. In some chronic cases with much infiltration, sulphur, 
resorcin, and salicylic acid may be with advantage combined in the 
same ointment, while in a few instances the tars, pyrogallol, or chrysaro- 
bin may succeed after the above-named preparations have failed. In 
acute forms, in which the symptoms are more those of an acute 
eczema, pastes and ointments containing salicylic or boric acid are 
valuable until the acute inflammatory condition has subsided, when 
preparations containing sulphur or resorcin should be used. 

The disease is usually more amenable to treatment than eczema, 
though recurrences are common. 



DERMATITIS REPENS. 

Under this title Crocker first described an inflammatory disease of 
the skin (usually a consequence of injuries) spreading with a marginate 
border, and, as a rule, beginning over the upper extremities. Cases 
have since been reported by Garden and Nepveu, Hartzell, 1 and 
others. 

The inflammation spreads from a traumatism, eventually producing 
a raw, reddish surface denuded of epidermis and oozing at several 
points, the serous exudate also undermining the apparently sound cuticle. 
The disease spreads with uninterrupted regularity, lasting for months, 
and in cases invading the larger part of an upper extremity. Exten- 
sion occurs by the appearance at the periphery, of new vesicles or small 
blebs, or by the elevation of the adjacent epidermis with the fluid exu- 
date. In either event, detachment of the epidermis leaves the char- 
acteristic, denuded, red surface. There is a definite margin to the 
diseased patch. The disease may begin with the formation of blisters. 

The disease has originated in cicatrices after amputation of a 
finger, from burns, from irritation of the feet after walking barefoot on 
sand, and from splinters under the nail. Crocker believes that the 
dermatitis results from peripheral nerve-irritation, and that there 
is a secondary parasitic involvement of the part. The disease seems 
to be an infectious dermatitis, the traumatism being simply an initial 
factor of the process. The parchment-like epithelium often left after 
healing shows that the process may be one of considerable destruction 
of epidermal and dermal tissues, which may result in diffuse but super- 
ficial atrophy and cicatrization. The diagnosis from eczema depends 

1 Jour. Amer. Med. Assoc, 1902, ii., p. 1581 (brief summary of reported cases). 



ECZEMA. 435 

chiefly upon the recognition of the limited outline of the disease, the 
entire denudation of the surface, the undermined edge, and the thinned, 
shining epidermis left after healing. The affection is to be treated as a 
parasitic eczema. 

Two cases of this disease were supposed to have originated in the 
minute traumatisms of the finger-nails occurring when farm-laborers are 
engaged in husking Indian corn by hand ; and one well-marked case 
followed the amputation of a finger. An excellent illustration of the 
disease is given in a colored lithograph accompanying the report of a 
case by Stowers. 1 

In three cases treated by us success was obtained in one after employ- 
ing locally a saturated solution of pyoktanin-blue. In another case that 
had resisted continued and varied treatment the lesions disappeared 
rapidly under application of a solution of sodium hyposulphite. Still 
another case yielded to applications of strong white-precipitate oint- 
ment. Crocker recommends a strong solution of potassic perman- 
ganate. 

Acrodermatitis Perstans (Acrodermites Continues [Hallo- 
peau]). — Under this title Hallopeau, Audry, Crocker, and others de- 
scribe a condition very similar to that of dermatitis repens in that it 
begins on, and often is limited to, the extremities ; originates frequently 
in traumatism ; begins often as a vesicle spreading peripherally ; and 
is rebellious to treatment. Hallopeau describes vesicular, bullous, and 
purulent types. The disease begins frequently on a finger, to which it 
may be limited for weeks before it commences to spread. On rupture 
of the vesicles or pustules a reddened excoriation is left similar to that 
seen in dermatitis repens. The condition differs from dermatitis repens 
in the frequent appearance of secondary eruptions, often pustular in 
form, on portions of the body even at a distance from the region first 
affected, and larger areas frequently are formed by the coalescence of 
a number of foci. The secondary eruption may be in the form of an 
exfoliative erythema, and may involve symmetrically considerable 
portions of the body. The disorder further differs from dermatitis 
repens in the tendency to recur frequently in the same place. It is 
also more persistent and occasionally terminates fatally. 

The disorder is allied closely both etiologically and pathologically 
to dermatitis repens. 

The treatment is practically the same in both disorders. For acro- 
dermatitis, Hallopeau recommends a solution of silver nitrate, 1 
drachm (4.) to the ounce (30.). 

PRURIGO. 

(Lat. prurire, to itch.) 

(Prurigo Gravis, Prurigo of Hebra, Prurigo Ferox.) 

Prurigo is a chronic, exudative, cutaneous affection, commonly 

beginning in infancy or early childhood, continuing through life, and 

characterized at first by urticarial symptoms, later by' the occurrence 

on the extensor surfaces of the extremities and also on the trunk, of 

1 Brit. Jour. Derm., 1896, viii., p. 1. 



436 INFLAMMATIONS. 

minute, pale or reddish, millet-seed- to hemp-seed-sized papules, with 
extensive infiltration, excoriations, pigmentation, furuncles, and intol- 
erable pruritus. 

Prurigo is one of those terms which in the past have led to consid- 
erable confusion in the nomenclature of cutaneous disease. In England 
chiefly it is applied with more or less looseness to disorders accompa- 
nied by the subjective sensation of itching, such as the prurigo mitis 
of Willan, and the disease well recognized under the title " pruritus." 

The title " prurigo " in this work is strictly limited to the disease 
to which the name was originally given by Hebra, a disorder beginning 
in earliest life and continuing throughout its duration. Once observed 
only or chiefly in Austria, it has now, in consequence of extensive 
immigration, been occasionally seen in America. 

Symptoms. — Mild and severe forms of the disease are distinguished 
under the terms Prurigo Mitis and Prurigo Ferox, or Agria. 
Incessant care, judicious treatment, climatic influences, and the com- 
forts of life commanded by wealth seem to determine the difference 
between the two. In both varieties of this affection pinhead- to rape- 
seed-sized, firm, whitish or reddish-white papules form, chiefly and 
primarily upon the extensor faces of the extremities, but from these 
localities gradually extend over the entire surface of the body. The 
itching is of the severest type. 

The earliest symptoms are usually displayed in the latter portion of 
the first year of life, in the form of an urticarial rash, which persists 
and which is finally succeeded by typical papules. These papules are 
minute, often subepidermic, and rapidly become covered with blood- 
stained crusts in consequence of the induced scratching. Then ensues 
a long train of symptoms, including pustulation, fissures, excoriations, 
dense infiltrations, crusts formed of exuded serum and dried blood, 
oedema, diffuse dark-brown pigmentation of the skin-surface in large 
areas, and consequent adenopathy. Fully developed, the disease pre- 
sents in general the same physiognomy in patients of different ages. 
The lower extremities always exhibit the severest manifestations of 
the disease, especially the thigh and leg as distinguished from the 
foot ; though the trunk, the forehead, the cheeks, the neck, the arms, 
and the head may also be involved. Protected surfaces, such as the 
axillge and the groins, except as regards adenopathy, are free from the 
disease. The general health of the patient manifestly suffers from the 
insomnia and nervous agitation induced by the state of the integument. 
Emaciation, malnutrition, and cachexia are common sequels. The 
mental and moral tone of the patient thus harassed from early child- 
hood throughout an entire life is necessarily profoundly impaired. 
Insanity and suicide are reckoned among its remote consequences. 

The characteristic papules first appear about the eighteenth or nine- 
teenth month of life, the urticarial rash up to the second year produc- 
ing merely whitish plaques upon the skin, commingled with excoria- 
tions and occasionally a marked degree of insomnia. The minute 
papules develop only later on the several regions of preference of the 
disease, at first appreciable only to the touch, later projecting from the 
surface and capped with a blood-scale from the scratching to which 
they have been subjected. Then are to be seen striated excoriations, 



PRURIGO. 437 

bulkier crusts, pustules, dark-brownish-hued pigmentation, and a 
rubbing off of the hairs, such as is often to be seen over the brows 
of male patients with erythematous eczema of the face. (Edema, 
infiltration, and axillary and inguinal adenopathy supervene, so that 
by the end of the second year or at the beginning of the third the pict- 
ure of prurigo is complete. At such an epoch the distinguishing 
marks of the disease are its selection of the extensor faces of the ex- 
tremities and the progression of symptoms with added severity from 
the arms to the legs. The natural furrows of the skin are all exag- 
gerated. In exceptional cases the lesions are seen over the face and 
the dorsum of the feet. Eczematous attacks may complicate any case. 
As a rule, the patient presents practically the same morbid portrait 
after maturity and even in old age as in earlier life. 

Prurigo mitis is the same as the severer form of the disease 
with respect to the evolution of symptoms ; the only difference to 
be observed is in their intensity. The papules are fewer, the recru- 
descence rarer, the itching less intense, and the amenability to treat- 
ment more pronounced. It is to be noted of all cases that they are 
influenced happily by the warm weather of the summer season and 
by special attention to cleanliness and hygiene. 

Etiology. — The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. Wigglesworth, Campbell, Zeisler, and others have 
reported cases in America. Prurigo is encountered more often in the 
male sex, is never contagious, and is never induced by lice ; but, accord- 
ing to Hebra and Kaposi, it may be grafted upon an hereditary pre- 
disposition. "Scrofula," tuberculosis, malnutrition, "misery/ 7 poverty, 
anaemia, and filth are held to be severally favorable to its development. 
The disease is practically limited to the poorer classes living under 
wretched hygienic and social conditions. The superior resources of 
the poorest classes in America will long protect them from the incur- 
sion of this inveterate malady. 

While typical prurigo ferox, as described by the Vienna school of 
authors, is of such rarity that probably less than a dozen cases have 
been reported in America, the opinion is gaining ground that the same 
disease with milder manifestations (prurigo mitis) is much more com- 
mon here than has been believed. Patients with severe prurigo, treated 
by Hebra himself, have found their way to our clinic ; they bore unmis- 
takable symptoms of improvement after a residence in the United States, 
and almost every American expert has observed cases of milder type. 

Pathology. — Kaposi practically admits that, striking as is the clin- 
ical portrait of this disease, its anatomical features are indistinguish- 
able from severe forms of obstinate papular eczema, or from other forms 
of chronic dermatitis accompanied by hyperplasia. The microscope 
reveals proliferation and swelling of rete-cells, cell-infiltration and 
oedema of the papillse, most marked around the vessels, and frequently 
dilated lymph-spaces. There is a scattered deposit of pigment in the 
corium, and many cutaneous muscles (erectores pilorum) are thickened 
and shortened. Holder J states that these muscles not only are hyper- 
trophied, but also are contracted, and that the papule has an urticarial 
basis. 

1 Jour. Cutan. Dis., 1901, xix., p. 489. 



438 INFLAMMATIONS. 

Some authors contend that the papules are solely due to traumatism 
of the pruritic skin. Auspitz believes that the disease is in fact a 
sensori-motor neurosis without essential lesion. Eiehl 1 considers it as 
a chronic form of urticaria. Leloir and others find the prurigo-papule 
invariably resulting from a cystic degeneration of rete-cells, thus form- 
ing a cavity which at first contains clear serum with the addition later 
of epithelial debris. The walls of the cyst later undergo keratin ization. 

Bernhardt, 2 after studying a typical case in a patient with a para- 
lyzed arm, believes the disease is a dystrophy of the corium due to 
chronic irritation of the trophic centres, and that the papule precedes 
the pruritus. 

White 3 concludes : " I cannot go farther than accept the existence 
of a condition of early childhood, allied to pruritus and urticaria in 
its visible manifestations, and not to be distinguished positively from 
them in its first stages, often becoming in certain parts of the world a 
chronic affection due to some inexplicable national cutaneous traits, or 
inherent customs of living, a condition which certainly lacks many of 
the essential elements of individuality." 

Diagnosis. — Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, by the course of the disease, by 
the age of the patient when it is first developed, by the great extent 
of the eruption, and by the uniform type of its lesions. In prurigo, 
also, the fingers and the toes, the flexor aspects of the extremities, and 
the face are more or less spared. Under treatment eczema commonly 
yields at least in some portions of the skin, while prurigo does not. 

From pruritus, prurigo is readily diagnosticated by its general 
physiognomy and history, by its peculiar pigmentations and infiltra- 
tions, and by the special region chiefly affected. But both diseases 
may complicate prurigo, especially eczema, which is then ordinarily of 
artificial origin. In pediculosis corporis the parasites will usually be 
found upon the underclothing, while the lesions induced by the finger- 
nails never form closely packed papules. There is something highly 
characteristic in the widely separated excoriations, the puncta from 
wounds inflicted by parasites, and the inflamed papules seen upon louse- 
bitten patients. 

In scabies the characteristic burrows of the parasites will usually 
be recognized, as also vesicular and pustular lesions. Urticaria can 
be mistaken for prurigo only in the earlier stage of the last-named 
disease. 

Treatment. — In Vienna, sulphur, naphtol, tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occasion- 
ally served to ameliorate the severe symptoms of the disease. Mer- 
cury, ichthyol, salicylic acid, carbolic acid, and boric acid, and diachylon 
and zinc ointments may also be employed upon different portions of 
the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 

1 Vierteljahr., 1884, xl., p. 41. 

2 Archiv, 1901, lvii., p. 175 (bibliography). 

3 Jour. Cutan. Dis., 1897, xv., p. 2 (review of subject, with bibliography). 



ACNE. 439 

and green soap, has proved of special value in many cases. Vle- 
minckx's solution (q. v.), followed by hot bathing and corrosive-subli- 
mate baths, 1 drachm (4.) of the sublimate to 30 gallons of water, 
has also been recommended. Fox ! reports a case relieved with sulphur 
and ichthyol ointments. Internally arsenic has proved valueless, while 
carbolic acid occasionally has seemed beneficial. Cod-liver oil and the 
ferruginous tonics with the bitters are indicated in many patients suffer- 
ing from malnutrition. A generous diet and a tonic regimen are essen- 
tial to the management of most cases. 

Prognosis. — The disease usually persists through life. The most 
favorable conditions are those in which the patient is young and sur- 
rounded by circumstances which permit of provision for his needs. The 
disease is probably curable in the early years of life. 

ACNE. 

(Gr. anvil, a point.) 

(Acne Vulgaris, Varus. Fr., Acne ; Ger., Hautfinne, Akne.) 

Acne is a chronic inflammatory disease of the sebaceous glands and 
periglandular tissues exhibited chiefly over the face, neck, shoulders, 
and anterior and posterior surfaces of the upper thorax, characterized 
by an eruption of papules, pustules, and smaller and larger nodules, 
usually intermingled with comedones, and often associated with sebor- 
rhea of the scalp. It rarely develops before the puberal epoch, and 
is unusual after the third decade of life. 

Symptoms. — Acne is probably the cutaneous disease of most com- 
mon occurrence, not excepting eczema. The latter affection occurs 
upon the face as often as upon other parts of the body, yet it is seen 
in persons upon the street with far less frequency than acne. Eczema, 
however, is more distressing in its symptoms, and for that reason 
physicians are more often consulted for its relief, the disease thus 
acquiring a statistical preponderance. Acne is more tolerable, and 
therefore is more tolerated and less treated, especially among the poor. 

The disease chiefly occurs in the second and third decades of life, 
and is characterized in general by the occurrence of several and usu- 
ally numerous, light-red, dull-crimson or violaceous, pinhead- to small- 
nut-sized, ill-defined papules, nodules, tubercles, or non-projecting 
indurations of the skin, often commingled with the symptoms of comedo 
and seborrhea sicca. The lesions are isolated or irregularly scattered 
over the surface, which," however thickly studded with them, never dis- 
plays a grouping or definite arrangement of the elements of the erup- 
tion. Many of the latter are both slightly painful and tender, though 
upon this point there is a wide range of difference in various indi- 
viduals, some patients tolerating with a surprising equanimity the most 
extensive invasions of the disease. The inflammatory process, which 
manifestly involves the sebaceous glands and periglandular tissues, 
may result in suppuration of several adjacent follicles, as a conse- 
quence of which coalescence occurs and pea- to large-nut-sized cuta- 
1 Jour. Cutan. Dis., 1903, xxi., pp. 148 and 229. 



440 INFLAMMATIONS. 

neous and subcutaneous abscesses may form. In many cases, however, 
the suppuration is limited to the area of the individual nodule. Every 
feature of the disease, from the smallest papule to the largest subcuta- 
neous abscess, may be displayed at the same moment in an affected in- 
dividual. Under circumstances of special aggravation the disease may 
occur in acute forms, but it is commonly chronic, the acute phases 
being usually accidents of the general process. 

The symptoms of acne are displayed most commonly over the face, 
but they are seen frequently upon the neck, the shoulders, the back and 
front of the upper chest, the genitals, and the extremities, and occasion- 
ally on other parts of the body, the palms and soles being excepted. 
The disease is intermittent in severity, the patient being at times rela- 
tively free from symptoms and at others conspicuously disfigured. In 
women the symptoms of the disease often are aggravated at the men- 
strual epoch, but this is not true of all cases. As a rule it is wholly 
unproductive of pruritic sensations. Very rarely the eruption is devel- 
oped acutely, being usually insidious in progress, and while it may 
occur as an accident in a person previously enjoying a wholesome 
complexion, it is seen more often in those having a thick, greasy, dark- 
tinted and often muddy skin. 

The disease may last for years when unrelieved, during this period 
being subject to frequent exacerbations and remissions, but it com- 
monly disappears spontaneously as full maturity of the body is attained. 
It may persist for years in a mild form with or without the occasional 
development of the severer grades. In aggravated cases in which sup- 
puration has been extensive it leaves indelible traces of its ravages 
in the form of scars. The various terms used in the description of the 
forms of the disease refer chiefly to its external features. 

Acne is a disorder which frequently is associated with mild or severe 
alopecia furfuracea and seborrhcea capitis, the totality of symptoms 
depending upon similar causes in the susceptible subject. 

Acne Artificialis. — Various substances, either applied topically 
to the skin or ingested, are capable of producing acneiform lesions. 
Among them may be named tar, which may prove an irritant whether 
employed externally or internally, and far more frequently the salts 
of iodine and bromine after ingestion. Tar-acne occurs both among 
workers in tar and in those subjected to the action of this substance for 
the relief of other cutaneous disease. Pinhead- to pea-sized, reddish- 
brown papules then form, at the apex of each of which is perceptible 
a minute blackish punctum, produced by the lodgement of a particle 
of the medicament in the orifice of a sebaceous follicle. Pustular 
and furuncular lesions are, however, also produced, such as occur 
in bromic and iodic acne. In the latter disease Adamkiewicz and 
others have demonstrated the presence of the drug in the contents of 
the pustular lesions. Chrysarobin and a number of other medicinal 
substances are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica are terms employed 
to designate merely the lesion-relics of the disease. In acne atrophica 
there is complete atrophy of the gland-tissue, indicated by a minute 
sunken pit in the site of the former orifice. In acne hypertrophica 
there are, in consequence of the periglandular exudation, a thickening 



ACNE. 441 

of the tissues about the acini, and a projection from the surface in the 
form of persistent, pea-sized, and indurated masses. 

Acne Cachecticorum or Scrofulosorum includes the symp- 
toms encountered in the subjects of struma, scorbutus, marasmus, 
chloro-ansemia, and tuberculosis. The lesions are developed more often 
on the trunk and the extremities than over the face, and are indolent, 
papulo-pustules, pinhead- to bean-sized, remarkable for their livid, 
purplish, lurid-red, or violaceous tint. The lesions rarely are indu- 
rated ; more often they are softish, pus- and blood-containing nodules, 
sluggish of career, leaving minute cicatrices. Their features are due to 
the general cachectic condition of the subjects in whom they occur. 
Colcott Fox describes acne scrofulosorum as it occurs in infants. 1 

Acxe Indurata. — This type of the disease is observed less fre- 
quently than several of the other forms, but it is one which possesses 
distinct clinical features. Induration of the base of the acne-papule 
may be noted in many cases of the simple form of the malady, but 
in others the glands seem generally to be distinguished as minute, 
very firm nodules, with no tendency to suppuration. The surface of 
the skin is often without marked change in color or heat, the indi- 
vidual lesions exhibiting at times an unnaturally whitish aspect. They 
are felt when the finger is passed over the surface as dense, often 
conical projections, occasionally painful, and giving to the touch a 
sensation suggestive of the surface of a nutmeg-grater. Comedones 
may often be discovered intermingled with the papules. The disease 
when well marked may be extensive, occurring with characteristic ex- 
pression among brunette, hairy male patients well advanced to the 
twenty-fifth year. It often is generalized over the forehead, cheeks, 
and chin, and the back of the neck. 

Acxe Papulosa. — In acne papulosa the lesions are of a papular 
type, ranging in size from that of a millet-seed to that of a coffee- 
bean, whitish or reddish in color, and varying in the amount of indura- 
tion at the base. They are evidently due to infiltration of the peri- 
glandular tissue, and are often commingled with pustules, papulo-pus- 
tules, and comedones. At the apex of each papule is often distinguished 
the blackish point characteristic of acne punctata, or a minute, greasy, 
yellowish- white spot, which represents the non-pigmented extremity of 
an inspissated sebaceous plug. 

Acxe Punctata. — In this variety of acne the apex of the papule 
exhibits the characteristic blackish punctum of the comedo about which 
the papule has formed. 

Acxe Pustulosa.— This is the most frequently observed of the 
expressions of the disease. The lesions are apt to be commingled with 
papules, comedones, and intermediate phases between the functional 
and inflammatory disorders of the glands. The pustules almost in- 
variably originate in previously formed papules and may be large 
or be small, containing merely a droplet of pure pus, or, when a true 
furunculosis ensues, a teaspoonful or more of pus may be mingled 
with blood and serum. This accumulation may be evacuated sur- 
gically or accidentally, or be absorbed, or may remain for a long 
1 Brit. Jour. Derm., 1895, vii., p. 341. 



442 INFLAMMATIONS. 

period of time in a species of cyst, whence it can finally be expressed. 
In aggravated cases two or more of these pustulo-furuncular depots 
may coalesce, forming nut-sized abscesses, or, not rarely, may become 
united by fistulous tracts, through which there is free communication 
of the fluid contents of two or more chambers. 

Acne Vulgaris is a term applied by several authors to the com- 
posite eruption which is common to many clinical cases. Here the 
various lesions described above (papules, pustules, comedones, etc.) 
are associated, usually on the face and over the shoulders, each in sev- 
eral degrees of development, often in conjunction with the scars left 
by a prior eruption. 

Acne Disseminata is a name given by some authors to acne vul- 
garis, the common inflammatory type of the disease above described. 

Acne Keratosa is the Acni cornee of French authors. In this 
affection cornified masses of sebum distend and project from the orifices 
of the sebaceous glands, particularly over the neck, but also over the 
face, the trunk, the elbows, the knees, and other portions of the body. 
There is some doubt whether this disease should not be classed with 
ichthyosis, which it unquestionably resembles, or with keratosis pilaris. 
By some French authors the condition is considered an early stage of 
keratosis (psorospermosis) follicularis. 

Under this title Crocker x reports four cases in women in whom there 
appeared on the face, chiefly about the angles of the mouth, firm, painful 
inflammatory papules, succeeded by pustules and crusts. From the cen- 
tre of these lesions could be expressed short, soft or horny plugs which 
were formed evidently in the sebaceous glands or hair-follicles. On 
removing the plug the lesions healed slowly, in many instances leaving 
a scar. The disease was persistent, lasting in one case for forty years. 
Keloid- acne (see Dermatitis Papillaris Capillitii) is a name 
which has been given to an inflammatory folliculitis and perifolliculitis, 
leaving deep hypertrophic scars, usually, in the thick epidermis over 
the neck and the back of the trunk, though seen also upon the scalp 
and face. Wisps of thick, distorted, and evidently altered hairs pro- 
ject here and there from the affected surface. Reddish, and even vas- 
cularized nodes, tubercles, and bridges occur at irregular intervals, in- 
terspersed with occasional acne-pustules and deep-seated, broad, even 
gigantic comedones. Sclerotic tissue, in brief, forms about the site of 
the acne-process quite like cicatricial keloid of the trunk and other 
situations. 

Acne Parasitica is a term which eventually will be extended to 
include many of the varieties of the disease described above. Some 
of the pustular lesions of acne result solely from dissemination of pus- 
cocci over the face by the finger-nails or other means. The good re- 
sults obtained by an appropriate therapy are often the fruit of a de- 
struction of these micro-organisms. 

That some of these lesions are at times infected with the bacillus 
tuberculosis there can be no question. Not only have tubercle-bacilli 
been recognized in the pustules of some forms of acne, but singular de- 
generative and even ulcerative results have in rare cases been produced, 
not solely due to the ordinary processes distinguishable in acne. 
1 Brit. Jour. Derm., 1899, xi., p. 1. 



PLATE VII. 




Aene-keloid of the Back, 



ACNE. 443 

Acne Ukticata is described by Kaposi, Toulon, Lowenbach, 1 and 
others, as occurring on the scalp, face, and other portions of the body. 
The primary lesion, which is preceded by itching aud burning, is a 
small wheal which enlarges to the size of from 6 to 12 mm. The 
centre then becomes paler and depressed and shows a vesicle which 
dries into a crust. The crust falls, leaving a small scar which in time 
becomes depressed and shining white. The full development of a 
wheal requires from four to six days. The later stages of the process 
suggest acne necrotica both clinically and histologically. 

Ulerythema Acneiforme is probably due in part to the toxins of 
a tubercular infection, and is assigned in this work to another chapter. 

Contagious Acne (Diekerhoff and Grawitz) of horses (horse-pox) 
is compared by Kaposi to contagious impetigo rather than to human 
acne. It is characterized by an eruption of flattish, pea-sized and 
larger bullae, seated on an inflammatory base, and visible over the 
region of the mane, the back, and the shoulders. 

Etiology. — The causes of acne are numerous and in many cases 
obscure. They are both systemic and local, for even the most ardent 
advocates of the parasitic origin of the disease must admit that pre- 
disposition, based on constitutional conditions, is an important factor. 
The disease occurs usually at the age of puberty, and in most instances 
disappears during the third decade of life, although it occasionally 
persists or even begins later. It is common to describe the puberal 
changes in both sexes as a frequent cause of the disease, but a physio- 
logical crisis is rarely a disease factor unless the normal development 
of the period be prevented by accident, illness, malnutrition, or by 
excessive demands upon the vital forces in other directions, such as are 
made too frequently of children in the public schools. With the 
growth of hair in both sexes in the period of puberty there is an 
unusual activity of the sebaceous glands, and this physiological is thus 
the more readily perverted to a pathological activity. 

The disease often is due to disturbances of the gastro-intestinal 
tract, including constipation and dyspepsia, and to malnutrition from 
various causes. The eating of indigestible food, overindulgence in 
alcohol, coifee, or tobacco, as w^ell as overeating, frequently cause a 
fresh outbreak of lesions in the predisposed individual. In the matter 
of diet individual peculiarities are evident. In individual cases the 
partaking of a certain article of food, such as milk, easily digested 
by most people, is sufficient to determine a fresh outbreak of acne. 
Certain drugs, more commonly the bromides and iodides, aggravate an 
existing acne. In women the disorder is frequently worse just before 
or during the menstrual period. The disorder appears at times to be 
a reflex neurosis. 

In many individuals suffering from acne no defect in the general 
health can be discovered. In some cases the disorder is limited for 
long periods of time to a few follicles or to a small area, and is un- 
doubtedly local in origin. Among the local conditions favoring the 
development of acne may be mentioned mechanical plugging of the 
sebaceous follicles, as w T ith dust and dirt; failure to remove with 
1 Archiv, 1899, xlix., p. 29. 



444 INFLAMMATIONS. 

soap and water accumulations at the mouths of the follicles ; irritation 
of the follicles by too frequent use of strong soaps or by the application 
of cosmetics ; contact with dyed veils ; and frequent fingering of the 
face which tends to disseminate over its surface pus-cocci and other 
micro-organisms which are undoubtedly active factors in some, if not 
all, stages and varieties of the disease. Unna and Sabouraud believe 
the organisms they find in seborrhoea are the active agents in the pro- 
duction of acne, with or without the addition of pus-cocci (see Sebor- 
rhoea). Gilchrist 1 finds in acne-lesions bacilli similar to Sabouraud's 
micro-bacillus. From firm papules in which clinical evidence of sup- 
puration had not yet appeared, he obtained in a large percentage of 
cases pure cultures of the bacillus, which he terms Bacillus acnes. 
He succeeded in cultivating this bacillus and showing it to be patho- 
genic for mice and guinea-pigs. The sera of patients affected with 
acne causes a clumping of the bacilli, from which fact he infers that 
" a specific toxic body derived from the presence of the bacilli in the 
tissues is absorbed in the blood, resulting in the production of the 
specific agglutinin." He even goes to the extreme of suggesting that 
the systemic condition found in many cases of acne, instead of having 
an etiological significance, may be the result of absorption of the 
toxins of bacilli acnes. 

Pathology. — The earliest stage of the acne-papule is that described 
under comedo. Hyperplasia of the horny layer at the follicle-neck 
may continue without decided inflammatory changes and produce the 
small, firm, normal-colored papules of this type of acne indurata ; or 
complete occlusion of the duct of the gland may result in a simple 
retention-cyst. As a rule, however, the retained sebaceous secretion 
acts as a medium in which pus-cocci rapidly develop, producing an 
inflammation which may be limited to the common excretory duct 
and the sebaceous gland, but which involves usually the hair-follicles 
and the tissues surrounding these structures. The pathological 
changes depend upon the extent and intensity of the process. All 
grades of severity are found between the superficial abscesses limited 
to the duct of the follicle, which disappear without leaving scars, to 
those instances where several glands and the intervening structures are 
involved in the formation of deep abscesses, which cause destruction 
of connective tissue and leave large disfiguring scars. In many of 
the nodules the inflammation is subacute in type, persistent, and is 
accompanied by infiltration of plasma-, mast-, and connective-tissue- 
cells, resulting in true connective-tissue proliferation and the consequent 
formation of indurated scars. 

Diagnosis. — The typical facies of acne vulgaris is readily recog- 
nized by the characteristic features already described. The reddish 
papules, pustules, comedones, and "lumps" in the skin of the face of 
a young subject; the evident involvement of the sebaceous glands; the 
history of a chronic affection destitute of itching and, though possibly 
picked, quite unscratched ; the occasional blood-crusts where lesions 
have been squeezed or incised, are all significant facts. The pustular 
syphilide of the face is not only to be differentiated by its share in the 

1 Trans. Amer. Derm. Assoc, 1902, p. 105; and Jonr. Cutan. Dis., 1903, xxi., p. 
107 (with review of work done in this field by other observers). 






ACNE. 445 

history of an infectious disease, but also by the occurrence of charac- 
teristic crusts, its selection by preference of the regions about the nose 
and mouth, its evolution in groups, and its sequels in the form of super- 
ficial or deep ulcerations. Nevertheless, simple acne is common in 
syphilitic subjects. Potassium iodide is so frequently administered 
for the relief of syphilis, and in so large a majority of cases induces 
its artificial acne, that the latter eruption often precedes the evolution 
of the macular syphilide, and also with frequency masks the latter by 
a commingling of lesions. Simple acne is common also among those 
who are veterans of syphilis. Acne certainly at times resembles variola, 
and cases of the former have been mistaken for variola. In most 
instances the absence of fever and a brief delay will end any doubt. 

Treatment. 1 — Acne is an entirely remediable disease in every case 
properly managed. Scars of ancient ravages of the affection are, it is 
true, indelible, but even these are smoothed down in the progress of 
time so that they become yearly less conspicuous and disfiguring. 

The general treatment of acne requires a careful and exhaustive 
study of the special requirements of each individual case. For most 
patients the question of diet is of the highest moment — that appro- 
priate for the school-boy and the school-girl, or the adolescent 
employed in factory or on the farm or in domestic labor. All well-fed 
subjects of acne are benefited in a high degree by reducing the quan- 
tity of food ingested, especially in the item of meats. A milk-diet, 
or one composed largely of fish, fruits, and the lighter vegetables, 
will usually brighten up the most obstinate case. Confectionery, 
highly spiced food, pastry, hot bread and cakes, sugars, and fried 
articles are all excluded with great advantage. In most cases much 
will be accomplished by cutting down the quantity while regulating the 
quality of the food eaten. Alcohol is generally to be prohibited ; and 
it is idle to treat a severe case of acne in a young male subject who 
cannot for the time abandon the use of tobacco in every form. 

An important consideration, at the outset of treatment of a patient 
affected with acne, relates to any local or internal medication previ- 
ously employed. A large proportion of all patients first claim the 
attention of the physician after ingesting drugs or making topical 
applications which have decidedly aggravated the original trouble. 
With or without the advice of others, such patients have often been 
engaged for months in swallowing potassium iodide, " red clover/' 
the " bromo," and similar proprietary preparations for the most part 
containing acetanilid purchased for relief of headache, and various 
nostrums calculated to " drive out " disease ; or in rubbing over the 
skin equally noxious proprietary substances. In every such instance 
the skilled physician should delay active treatment of the affection 
until the artificial acne has subsided, and the real condition of affairs 
can clearly be recognized. The patient should be directed to discon- 
tinue his or her former practice, to bathe the affected part with hot 
water at night, and after the surface is dried to apply any bland un- 
guent. By these simple measures alone many cases can be improved 
greatly, and some be relieved completely. 

1 For a discussion on the treatment of acne before the American Dermatological 
Association, see Trans., 1902, p. 119 ; and Jour. Cutan. Dis., 1903, xxi., p. 136. 



446 INFLAMMATIONS. 

The constitutional treatment of acne rests for its success upon the 
discovery of the cause of the disease. Many patients certainly require 
no internal medication, being entirely relieved by local treatment. A 
thorough investigation of the habits of living — food, diet, bathing, 
occupation — and bodily functions, according to the methods described 
in the chapter devoted to General Diagnosis, is essential at the outset. 

Since dyspepsia and constipation are frequent causes of the disease, 
it is necessary to correct these disorders when present. A blue pill or 
calomel on several consecutive nights followed by a saline laxative in 
the morning is usually indicated at the outset of treatment. The 
cascara compounds are especially valuable when it is necessary to con- 
tinue the use of a laxative for more than a few days. Some modifica- 
tion of Startin's acid mixture, such as the following, will be found 
suitable for other cases : 



R Magnes. sulphat., 


S« ; 60 




Acid, sulphur, dil., 


f 3ij ; 8 




Sodii chlorid., 


3 j ; 4 




Ferri sulph., 


gr. v; 


33 


Cardamom, tinct. co., 


f'3j; 4 




Aq. dest., 


ad f Sviij ; ad 240 


M. 


Filtra. 




Sig. A tablespoonful in a 


tumblerful of water before breakfast. 



Other cathartics, saline and alterative, will often prove service- 
able. The mineral waters, Hathorn, Carlsbad, Hunyadi Janos, Eacoczy 
or Kissingen, a tumblerful before breakfast, are exceedingly valuable 
in cases of habitual intestinal torpor. When there is an acid form of 
dyspepsia the rhubarb and soda mixture, or potassium acetate in 1 
drachm (2.) doses, will be serviceable. Mercurous iodide in small doses 
three times a day is often of value in aiding elimination. Some cases 
improve rapidly on taking each night enough castor-oil to cause a daily 
free evacuation of the bowels. Salol and other intestinal antiseptics are 
effective in some cases. 

In many cases of acne due to inactivity of the large intestine 
thorough irrigations of the bowel, together with daily exercises which 
will strengthen the abdominal muscles and stimulate peristalsis, are 
followed by complete recovery. Large quantities of pure water drunk 
between meals and before meals aid greatly in the matter of elimina- 
tion. As a rule, it is advisable to take little or no liquid — especially 
if iced — with food, or for an hour after eating. The unwholesome habit 
of rapidly bolting food without proper mastication is thus largely over- 
come. In many instances, however, a cup of warm, but not strong, 
tea, cocoa, or coffee at the close of the meal is an aid to digestion. 

Daily exercise in the open air is necessary to stimulate sluggish 
glandular systems into proper functional activity. Such exercise to be 
of value should be carefully adjusted, both in kind and in amount, to 
the needs of the individual. 

A most important part of the treatment in every case is without 
question the daily bathing of the entire surface of the body (with 
exception of the face, which requires special attention as elsewhere 
shown; and excluding the menstrual period in women) with water 



ACNE. 447 

as cool as can be tolerated, by rapid sponging, followed by brisk 
friction with coarse towels or with a flesh-brush until the skin is 
glowing. Common salt may be added to this bath in the strength of 
I pound of salt to each gallon of water. The results of this treatment 
are excellent in the majority of cases, especially in those in which the 
patient has been accustomed to the hot or Turkish bath, which may 
aggravate affections of this class. 

In nervous and overworked patients sufficient sleep at regular hours 
should be secured, and when possible short periods of rest during the 
day should be obtained. In some of these cases the indigestion and 
consequently the acne can be made to disappear with no other treat- 
ment than ten minutes of complete physical and mental relaxation 
before meals, and half an hour of comparative inactivity after eating. 
In a growing boy or girl relief of acne often can be best accomplished 
by shortening the school-hours, and by carefully selecting studies and 
occupation adapted to the physical and intellectual development of the 
individual. 

The sexual life of both the married and the unmarried should be 
regulated according to the laws of hygiene. Uterine disease, when 
this complication exists, should receive proper treatment ; and this, far 
less by topical applications than by attention to the general health, as 
patients of this class are often chlorotic young women with menstrual 
derangements, leading sedentary lives, or overworked at the school-desk, 
the sewing-machine, or the shop-counter. 

With the recognition of the several causes of acne, general and 
local, internal medication for the relief of the disorder should be 
directed wholly to the general condition of the patient. Calcium sul- 
phide, long highly esteemed hi the management of acne, is set down 
to-day as " side by side with the ludicrous specimens of therapeutic 
empiricism. " Arsenic, however, is highly recommended in acne papu- 
losa by Duhring and Taylor. The internal employment of ergot 
in full doses for the relief of acne has occasionally been followed by 
excellent results. Cod-liver oil, iron, strychnine, phosphorus, the 
mineral acids, and the bitters are needed in chlorosis and cachexia. 
Glycerin in teaspoonful to tablespoonfal doses three times daily has 
proved valuable (Gubler). Pepsin, pancreatin, and other aids to diges- 
tion are often of temporary value. 

In all cases, whether previously treated or not, which have been 
purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed lies the key to success. It is not the selection of one of the 
several remedies of the many advocated for the relief of the disease, nor 
yet the successive substitution of one for another to meet any transitory 
indication in each case, that conduces to the happiest result ; but it is 
rather the use of a single method of recognized value, and its skilful 
adaptation to the changing conditions of the disease. 

For many cases of acne the most rapidly effective local treatment is 
found in the skilful use of the a-rays. Under their influence pus- 
formation ceases, and the lesions usually disappear. We have used 
the treatment in fifty-seven cases, in the majority of which the usual 
methods of treatment had been unsuccessful. In twenty-one cases the 



448 INFLAMMATIONS. 

lesions were removed completely; in twenty-three, the improvement was 
very great ; seven showed some improvement ; in five, the results are 
unknown. In one case only, after faithful trial, the treatment proved of 
no benefit. In the majority of instances constitutional treatment was 
employed according to the indications in each case, but as a rule all 
other local treatment was suspended. In several exceedingly stubborn 
and severe cases, in which the skin of the face was studded with large 
papulo- pustules and small abscesses, and in which both local and gen- 
eral treatment had failed to give more than partial and temporary 
relief, a few weeks' treatment with the #-rays caused complete disap- 
pearance of the lesions. In several cases in which the lesions were 
limited to a few follicles or small areas the treatment was rapidly effec- 
tive and no recurrences have been noted. When there is constitutional 
disturbance and when the lesions are disseminated over the face, the 
lesions may recur, but apparently less frequently and not so promptly 
as after the ordinary methods of local treatment. We have had, on 
the whole, better results in all forms of acne from radiotherapy than 
from any other one local method of treatment, but for permanent 
results we find it must be supplemented in most cases by proper 
hygienic control and systemic treatment. 

Many other observers, among them Pusey l and Campbell, 2 report 
equally favorable results from the x-rays. 

The technique is practically that recommended for psoriasis except 
that the treatment is made somewhat more vigorous by increasing slightly 
either the frequency of the sittings or the duration of each exposure. 
In deep-seated lesions a somewhat harder tube may be used. As a 
rule the treatment is carried to the point of produciug a slight erythema 
or beginning pigmentation. The exposures should, however, never be 
carried to the point of producing dermatitis. In three instances we 
have seen (what is also reported by other observers) the disappearance 
of the acne-lesions followed by a slight hypertrichosis. The treatment 
is therefore contraindicated in women and girls who show any tendency 
to unusual development of lanugo-hairs. In two patients who had been 
subjected to several courses of the treatment because of recurrences, the 
acne-lesions had disappeared entirely, but the skin was slightly atrophic, 
being abnormally smooth, thin, and dry. In the treatment of unusually 
stubborn cases the operator always should bear in mind the dangers 
attending the long-continued use of even mild exposures to the arrays. 

An effective method of local treatment is found in curetting the 
lesions as practised by Fox, of New York. A ring-curette is drawn 
over the affected surface so as to express the contents of the lesions and 
to stimulate others to activity. The subsequent bleeding is encouraged 
by sponging with hot water. All comedones are expressed, and the 
subsequent treatment is that suggested below. 

It is always necessary to evacuate the contents of pustules, to express 
from the summits of papules (where are the orifices of sebaceous ducts) 
all densely inspissated plugs of sebum, and to remove any comedones 
present with the aid of the comedo-extractor. In many cases this oper- 
ative treatment, especially the removal of comedones, is easier and more 

1 Pusey and Caldwell, Rontgen Rays in Therapeutics and Diagnosis, Philadelphia, 
1903, 2 Jour. Ainer. Med. Assoc., 1902, xxxix., p. 313. 



ACNE. 449 

satisfactory after several days of the hot bathing and ointment-applica- 
tions recommended in the following paragraphs. For the purpose of 
opening the superficial and smaller purulent collections the long needles 
used by gynaecologists are decidedly preferable to a knife, and for the 
larger and deeper furuncular lesions a bistoury with a delicate and very 
narrow blade should be used. A slight degree of skill will here repay 
the operator. Piffard's acne-lance is useful in this connection, as 
also is Volkmann's spoon (modified by Auspitz), which may be em- 
ployed in removing pathological debris. By counter-depression with 
the fingers the whitish-yellow or blackish orifice of the duct may be 
detected, and at this point the needle or the bistoury should be thrust 
sufficiently deep to insure removal of pent-up pathological accretions. 
Should blood flow in droplets from any of these slight wounds, 
it is rather to be encouraged than repressed, as relieving the hyper- 
emia and engorgement of the small periglandular phlegmon. In one 
or several sittings all lesions requiring such interference should care- 
fully be attacked, and immediately after each operation, preferably 
while pus and blood still are oozing, the part is to be bathed for sev- 
eral minutes with water as hot as can be borne with comfort. For 
many reasons the hour before retiring is preferable, though not always 
practicable, in treating such cases, as then a bland ointment can thor- 
oughly be applied and be permitted to remain until the following 
morning. 

When one or several of these operations have largely relieved the 
skin of its engorgement and retained inflammatory products a systematic 
use, at night, of the spiritus saponis alkalinus or tincture of green soap 
(q. v.) with hot water, should for a time be practised. Many cases, 
which do not require the minor surgical operation described above, 
should from the first be treated in the following manner. As the face 
is the commonest seat of the disease, for the purpose of description, 
it may be considered as the affected part : 

The patient is seated before a basin of water, which is as hot as can 
be tolerated with comfort, and, with a pad of white flannel or a soft 
sponge, the face is bathed until the skin is thoroughly moistened and 
softened by the heated water and steam. From ten minutes to half an 
hour may well be employed in this way, it being a fertile source of the 
improvement which follows. While the face is still wet all pustules 
which have formed are emptied, and a sufficient quantity of spirit of 
green soap is poured over the flannel or the sponge, with which the face 
is then thoroughly scrubbed. Finally, the skin-surface is cleansed with 
a surplus of the water, is carefully dried, and is anointed with a sulphur 
ointment. 

Some range may be observed in the employment of the two sub- 
stances named. Thus, the spirit may be diluted with cologne- or rose- 
water, one-half or more ; or the soaps employed, in less imperative 
cases, may be the best toilet-soap, Sarg's glycerin or sulphur soap. 
The ointment, too, may be compounded by adding from 15 grains 
to 2 drachms (1.-8.) of sublimed sulphur and half of the same quantity 
of resorcin to the ounce (30.) of lanolin, cold-cream salve, or vaselin. 
In the morning the face is to be washed with cold water. 

29 



450 INFLAMMATIONS. 

This operation of steaming, soaping, and anointing is to be contin- 
ued, according to the severity of the case and the tolerance of the 
patient, nightly, or twice a day, or on alternate nights, until the face 
is free from papules and other inflammatory lesions. After from two 
to ten days of this vigorous treatment the face is usually unsightly, 
reddened, slightly tumid, and often moderately furfuraceous. To the 
patient the skin feels tense, slightly painful, and as if made of leather. 
When this artificial dermatitis is severe the hot water and ointment 
may be employed for a few occasions without using soap. For sensi- 
tive skins it may be necessary to employ for a few days some of the 
sedative lotions and ointments recommended for the treatment of acute 
eczema. When the artificial dermatitis has subsided the shampoo may 
be resumed. With the removal of the lesions the spirit, or other prep- 
aration of soap, may for a time be discontinued. The improvement 
which follows is marked and speedy, and usually is satisfactory to the 
patient. When this condition is reached a wider latitude of treatment 
is permitted. Gradually the hot ablutions may be withdrawn, and the 
use of less stimulating lotions and ointments may be advised. Sulphur, 
having the highest reputation in the disorders of the sebaceous glands, 
is a constituent of many of the lotions thus employed. One of the best 
is Vleminckx's solution (see page 98), of which from 5 to 50 drops in 
a tablespoonfnl or more of water may simply be mopped on the face 
and allowed to remain over night, or may be applied with gentle 
friction and massage. 

Taylor 1 advises the following : 

R Sulphuris loti, 

Camphorse spts., 

Sodse biborat., 

Glycerin., 

Aq. fontan., ad f|iv; ad 120 M. 

Sig. Shake well and apply freely, leaving a thin film of powder over 
face. 

Various combinations of sulphur with alcohol will be found useful. 
Thus, Kaposi recommends a paste composed of: 



M. 



3iij ; 


12 


f 3iij ; 


12 


3ij ; 


8 


f3vj; 


24 


f#v; 


ad 120 



R Sulphur, prsecip., 


Sijss ; 10 




Spts. vin. rect., 


f 5jss ; 45 




Lavand. spts., 


f Sijss ; 10 




Glycerin., 


"Ixx; 1 


33 


Sig. To be spread over 


the face and retained during the night. 


Or, 




R Sulphur, flor., 


3ijss ; 10 




Spts. sapon. virid., 


f 3v ; 20 




Lavand. tr., 


f 53; 60 




Peruv. bals., 


ttlxx; 1 


33 


Camphor, spts., 


T»lxv; 1 




Bergamot. ol., 


n\,v; 


33 



M. 



Sig. To be applied over the face at night. 
1 American Clinical Lectures, New York, 1878, vol. iii., No. 10. 



B Sulphur, praecip., 




3ij; 


8 


Glycerin., 




f 3ij ; 


8 


Alcoholis, 




fS; 


30 


Aq. calcis, 




fsj; 


30 


Aq. ros., 




f3ij; 


60 


Sig. Shake the vial before 


using. 







ACNE. 451 

Duhring recommends the following : 



M. 



Resorcin, next to sulphur, is probably the most valuable remedy in 
acne as in other sebaceous gland disorders. It may be used in the 
above formulae in place of sulphur, or combined with it in strength 
varying from 2 to 10 per cent. Ichthyol and thiol are similar in their 
action to sulphur, and sometimes succeed when the latter fails. They 
may be used in ointments, in lotions, or combined with glycerin. The 
discoloration produced is easily removed, as both substances are soluble 
in water. 

Ammoniated mercury, 2 to 15 per cent., in lanolin or other 
simple ointment is an effective remedy. Mercuric chloride is very 
generally employed in the strength of from -J- to \ grain (0.008-0.033) 
to the ounce (30.) of emulsion of bitter almonds as a lotion ; and the 
protiodide and biniodide of the metal are similarly applied in lotions 
and unguents, in the strength of from 5 to 10 grains (0.33-0.66) 
to the ounce (30.). One should be careful not to make use of mercu- 
rials at the same time with a compound of sulphur, lest a chemical 
combination occur by reason of which mercurous sulphide (sethiops 
mineral) be precipitated upon the skin and produce the appearance of 
comedo. 

For mild cases an excellent lotion is obtained by adding 2 drachms 
each (8.) of simple tincture of benzoin and glycerin to 4 ounces (120.) 
of distilled water, to which, where a more stimulating effect is desired, 
1 ounce (30.) of cologne-water or of alcohol may be added, or 1 scruple 
(1.33) of sulphurated potassa. 

Occasionally rumex ointment may be used with advantage as the 
basis of sulphur and other salves in acne. It is prepared according to 
the following formula : 

R Rum. crisp, rad., %ix ; 270 

Adipis, gvj ; 180 

Cerseflav., J j ; 30 

Aq. pur., q. s. q. s. 

Wash and bruise the roots ; boil for two hours ; strain ; evaporate to 4 

ounces (120.); gradually add the wax and lard in a melted state; and 

stir until cool. 

The English sulphur hypochloride, in ointments of the strength of 
those given above, and sulphurated potassa, \ to 1 scruple (0.66-1.33) 
to the ounce (30.) of lotion or of ointment, are effective, but objection- 
able on account of their odor. 

Mercurial plaster may be applied on strips of linen or iodated gly- 
cerin (5 parts of each of pure iodine and potassium iodide to 10 of 
glycerin) may be applied with a brush twice daily until from six to 
twelve applications have been made. Van Harlingen employs 1 



452 INFLAMMATIONS. 

drachm each (4.) of sulphurated potassa and zinc sulphate to 4 ounces 
(120.) of rose-water. Fox applies ^ drachm (2.) of chrysarobin to the 
ounce (30.) of collodion. Taylor advises from 5 to 25 grains (0.33- 
1.6) of zinc iodide to the ounce (30.) of vaselin. 

The paste recommended by Lassar is useful in some cases — that is, 
1 part of beta-naphtol, 2^- parts each of vaselin and sapo viridis, and 5 
parts of precipitated sulphur — spread over the skin for from fifteen to 
twenty minutes, and then wiped off, when the surface is dusted with 
French chalk. In obstinate cases with few lesions the touching of the 
parts with pure carbolic acid or with salicylic acid, or with acid nitrate 
of mercury, is useful, but such measures should be condemned for the 
majority of patients at or near puberty. A fine needle connected with 
the negative pole of a galvanic battery may be employed to destroy 
single and indurated papules or papulo-pustules. 

For chronic and indolent cases one of us devised a modification of 
the local treatment of acne by the aid of an instrument called the 
" massering-ball," figured on page 104. This instrument consists of a 
stout, short handle of hard rubber, connected by means of a slender steel 
neck with a ball set in a steel socket, the small sphere rotating within 
the cup of the socket, as in an ordinary ball-and-socket joint. The free 
play of the ball is aided by its bearing upon a smaller ball set in the 
neck of the cup attached to the handle, which is fixed upon the socket 
at an angle sufficiently convenient for the operator, whose eye can thus 
better follow the play of the ball. The ball is constructed of hard rubber, 
and the area of its impact upon the skin at any moment is about that 
of the human thumb of average size similarly placed. When actually 
in use the ball travels with ease as well along the angles of the nares 
with the cheeks, the bridge and root of the nose, and the regions below 
the symphysis menti, as over the brow, the temples, the chin, and the 
cheeks. When necessary to cleanse the instrument the ball is detached 
by unscrewing; but the entire instrument may be boiled without 
impairment of its usefulness. 

When ready for treatment the skin is first operated upon with 
aseptic needle and comedo-extractor until all pustules and subepidermic 
foci are emptied and conspicuous comedones are removed. After this 
the surface is rendered aseptic, either with one of the bichloride lotions 
or with a solution of formalin (40 per cent, of formic aldehyd) in the 
strength of from 0.5 to 2 per cent., according to the sensitiveness of 
the patient's face. The massering-ball is then rotated freely over the 
surface, and deep pressure is made upon the affected region, with the 
result of bringing into view groups of previously inconspicuous come- 
dones, which are in turn removed by the extractor or "presser." 
Lastly, massage of the surface is practised with the ball by the aid 
of a salicylated cocoanut-oil or by one of the sulphur unguents. 

The use of caustics in acne, though recommended, should in general 
be discountenanced as needless. In extreme induration of the lesions 
these may be rubbed with fine pumice-stone until the desired effect is 
produced. 

The powders employed in the milder forms of the affection are finely 
powdered sulphur, which may freely be dusted over the face, and those 



ACNE. 453 

compounded in various proportions of starch, rice-flour, zinc oxide, and 
bismuth subcarbonate. 

Relief of acne in young male patients has been reported after the 
passage of the urethral sound, and in both sexes by hot- and cold- 
water injections of the vagina and urethra. 

Prognosis. — The majority of patients, even when untreated, even- 
tually recover. This natural involution of the disease is commonly 
attained in proportion as the body arrives at the maturity of its devel- 
opment and accomplishes the sum of its important functions. Appro- 
priate treatment has, however, a satisfactory influence in hastening the 
recovery of a large number of all patients. A small minority suffer 
from the unsightly complications and sequels of the malady (cicatrices, 
keloid). Exceedingly rebellious and even grave cases occur in the 
cachectic, those long and improperly treated, and those who from 
necessity are continuously exposed to influences unfavorable to the 
involution of the disorder, such as the subjects of epilepsy habitually 
ingesting potassium bromide, and the victims of syphilis requiring 
persistent use of the salts of iodine. 

ACNE ROSACEA. 

(Rosacea, Gutta Rosea,Telangiectasis Faciei, JN^vus Araneus, 
" Brandy-nose/' Copper-nose. Fr., Acne rosee, Coupe- 
rose ; Ge?\, KlTPFERROSE, KUPFERFINNE.) 

Acne rosacea is a chronic disease of the skin of the face, often 
developed from or associated with the lesions of acne vulgaris, and is 
characterized by hyperaemic areas, or patches of dull-red erythema, 
telangiectases, inflammatory papules, or growths which may attain the 
size of a hen's egg. 

Symptoms. — Acne rosacea is displayed most often upon the nose, 
cheeks, and chin, but may occur on any part of the face, and rarely 
on the lateral regions of the neck. It is seen usually in middle life, 
and occurs rarely before the twenty-fifth year. In a first grade there 
is a more or less diffuse pinkish or dusky, but transitory redness, in- 
volving the extremity of the nose and its contiguous parts, which col- 
oration may extend from this region in a somewhat symmetrical figure 
over the brow, cheeks, and chin. The redness may be spread uni- 
formly over the regions involved, or displayed in irregular, ill-defined 
blotches which vary greatly in size and shape. The spots may be 
roundish, radiating, stellate, linear, tortuous, or of fantastic outline. 
The colors vary from a delicate rosy-pink to a deep-purplish crimson. 
Minute capillaries often ramify over the erythematous surface. The 
effect is a marked unsightliness, for which chiefly, or only, the advice 
of the physician is sought, as the affected parts give rise to few or no 
subjective sensations. Under pressure with the finger the color dis- 
appears, the surface seems cool rather than hot, and the sebaceous 
glands are seen to be affected, as there is usually present either a seb- 
orrhea oleosa or an accumulation of yellowish-white, moderately 
inspissated sebum in the patulous orifices of the gland-ducts. 

The disorder varies greatly with the general condition of the patient. 



454 INFLAMMATIONS. 

At times it may scarcely be perceptible ; again, after the stimulation 
produced by ingested food or by alcohol, after mental excitement, a 
paroxysm of coughing or laughing, or exposure to external irritation 
the lesions may be conspicuously deforming. This condition may 
endure for months or for years and then disappear, or may be suc- 
ceeded by a second stage of the malady. 

In a second grade of the disease the redness becomes permanent, 
though subject to frequent variations in intensity, capillaries dilate 
passively and appear as conspicuous, tortuous, straight, or anastomos- 
ing lines of reddish color about the nose, cheeks, chin, or forehead. 
Firm, purplish-red, painless, pinhead- to pea-sized nodules or papules, 
at times pustules, often rise from the erythematous surface, and they 
either display minute superficial and tortuous blood-vessels in the in- 
tegument with which they are covered, or they project from a base 
about which such a telangiectasis has very irregularly been developed. 
The lesions are apt to be intermingled with those of seborrboea oleosa, 
comedo, or with acne vulgaris. When fully developed, this stage of 
the disease, though generally not productive 'of marked subjective 
sensation, produces an exceedingly conspicuous deformity. 

In the third stage (which is the most pronounced of the three) 
roundish, sessile or pedunculated, lobulated or pendulous, firm, elastic, 
pinkish-red, bluish, livid, or violaceous vegetations, traversed by a finer 
or larger network of blood-vessels, slowly develop about the affected 
part of the face, chiefly the nose. These vegetations may be single or 
multiple, and in the latter case may be isolated or so closely united as 
to be scarcely distinguishable from one another. The acneiform lesions 
seen in the second grade of the disease may here also be apparent. 
The nose is often cold to the touch when bright red in hue, and it may 
be oily or greasy in appearance in consequence of a seborrhoea oleosa 
of the part. The so-called "brandy-drinkers'," " wine-drinkers'," 
and " whiskey-drinkers' " noses are of this class. In some cases there 
is a uniform and symmetrical hypertrophy of all the soft parts of 
the nose, which may thus attain colossal proportions. It is these 
extreme consequences of acne rosacea to which the term Rhinophyma 
has been applied. 

The course of the disease is slow, and in the larger number of 
patients does not produce the exaggerated types of the second and third 
grades. The lesions may persist indefinitely as indolent symptoms of 
the malady in any one of its stages, or in a case in which there has 
been no new-growth of vessels or of tubercles may proceed to spon- 
taneous involution. 

The Rosacea Acuminata of Crocker is characterized by the devel- 
opment on the face of few or numerous pinhead-sized convex red 
papules with an occasional seropurulent apex. The description given 
suggests Folliclis (q. v.). 

Etiology. — The first and second grades of acne rosacea are common 
in women either at puberty or near the period of the menopause, in 
those who are pregnant, or in those who suffer from utero-ovarian 
disease, frequent miscarriages, sterility, irregular performance of the 
menstrual function, or chlorosis. 



ACNE. 455 

The disease, however, is seen in men of early and of late adult life 
In both sexes it may occur in anaemic and asthenic states ; in both, also, 
its association with gastro-intestinal dyspepsia, constipation, and the 
immoderate use of strong tea and alcoholic drinks — beer, wine, and 
spirits — is a matter of common observation. According to Kaposi, 
the rosaceous nose of the wine-drinker is bright red ; that of the beer- 
drinker, cyanotic or violet ; that of the spirit-drinker, smooth, supple, 
fatty, and dark blue. The new growth of vessels and tubercles, with 
the rhinophyma of the advanced grade of the disease, is much com- 
moner in men than in women. In those whose faces are bronzed by 
exposure to the weather the telangiectasic condition of the cheeks, 
rather than of the nose, is of frequent occurrence. "V eteran sailors and 
soldiers are thus commonly affected. Persons who have frozen the 
nose or the cheeks on one or more occasions and those suffering from 
trauma of these parts are similarly liable to telangiectases. Any ex- 
ternally or internally operating cause which tends to retard the capillary 
circulation in the superficial portion of the skin is capable of inducing 
this result. Acne rosacea at times is displayed conspicuously in the 
mulatto. 

Pathology. — In the first stage of acne rosacea there is merely pas- 
sive hyperemia. The circulation in the superficial capillary plexus is 
retarded. Persistence of this condition for long periods of time results 
in paresis of the capillaries, with their consequent dilatation and hyper- 
trophy, phenomena which characterize the second stage, the sebaceous 
gland-disorder being a complication of the process. In the third stage 
the nodules are composed of newly formed gelatinous elements, which 
later are replaced by organized connective tissue. 1 According to Biesia- 
decki, there are also dilatation and hypertrophy of the sebaceous glands, 
with dilatation, hypertrophy, and new growth of the superficial blood- 
vessels, and enlargement also of those trunks which ascend from the 
corium. There is no marked epithelial hypertrophy (Unna). 

The disease, however, is viewed differently by authors. By some its 
obvious connection with acne vulgaris is denied ; by others it is 
regarded as a seborrheal eczema. According to Besnier and Doyon, 
this disease represents : (a) superficial or deep, at first intermittent, 
then persistent, hyperemia ; (6) sebaceous hyperemia (acne-eczema), in 
which there are unquestioned steatorrhea and implication of the seba- 
ceous glands with infiltration and possibly exfoliation of the skin ; (c) 
deep hyperemia with infiltration of the corium and plastic products 
about vessels, follicles, and perifollicular tissue ; (d) telangiectases, as 
described above ; and (V) hypertrophies of the perifollicular derma with 
connective-tissue new-growth. 

Diagnosis. — Acne rosacea is distinguished from acne vulgaris by 
the presence of telangiectases, and of the hypertrophic growths 
which characterize fully developed lesions. The tubercular syphilo- 
derrn is recognizable by its tendency to ulceration and crusting and 
by the entire absence of telangiectasis. When the tubercles of syph- 
ilis are limited to the extremity of the nose (they are usually small in 

1 For histopathology of the severe type— rhinophyma— see Salzer, Archiv, 1901, lvii , 
p. 409 (with review of literature). 



456 INFLAMMATIONS, 

consequence of the influence of treatment) they often degenerate into 
characteristic, split-pea-sized, irregularly circular ulcerations, which 
are superficial in seat and frequently isolated. They leave similarly 
shaped and sized depressed cicatrices at the tip and neighboring parts 
of the nose. As the process is much more rapid than in acne rosacea, 
these lesions, considered in connection with the absence of telangiec- 
tasis, furnish the most significant diagnostic symptoms of the disorder, 
for they often occur late in the history of syphilis, in individuals in 
middle life, and in varying shades of a dull-reddish color, circum- 
stances particularly favorable for confusion regarding the identity of 
the two diseases. 

Zoster from involvement of the superior maxillary branch of the 
trigeminus, with diffused redness of one side of the nose and efflores- 
cence of vesicles over its tip and ala, strongly resembles acne rosacea 
with pustular lesions ; but in zoster the painful character of the dis- 
order, its limitation to one side of the face, its transitory career, and 
its vesicular lesions are characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to ulcer- 
ation and crusting, by the absence of vascularity, and by the frequent 
presence of characteristic cicatrices. Unlike syphilis and acne rosacea, 
however, the history of lupus vulgaris usually extends from early 
childhood. Lupus erythematosus is characterized by a definite outline, 
by a superficial infiltration and elevation of the border of the patch, by 
an atrophic or scarred centre, by adherent scales, and by its symmetri- 
cal diffusion over much larger and defined areas, commonly extending 
from the bridge of the nose well on to the cheeks. 

Treatment. — So far as there can be said to be any internal treat- 
ment of acne rosacea, it is that employed in acne vulgaris ; but in 
neither disease can such treatment be confidently described as effective 
in the dispersion of the local lesions. The treatment is that of the 
patient rather than of his disease. When alcohol has been in any 
degree productive of the local effects the use of spirits, wines, and beer 
is to be interdicted ; but as regards confirmed rosacea this prohibition 
will prove to be of little avail. The disease when resulting from 
spirit-drinking may persist after years of total abstinence. 

The diet should be of the character proper for the patient with 
acne. All imbibition of hot liquids, even tea and coffee in excess, 
should be restricted as tending to congest the blood-vessels of the face. 
Everything having the same result in the habits, the occupation, or the 
clothing of the patient should be, as far as possible, deprived of 
influence, as, for example, wearing of tight collars and corsets, working 
over hot fires, etc. 

In many patients who are the subjects of rosacea, as distinguished 
from the younger class of sufferers from acne vulgaris, there are evi- 
dences of lithsemia, gout, and similar conditions, requiring even stringent 
rules in many particulars for the conduct of life. The use of sugar 
in many of these cases is to be restricted, meat should be forbidden or 
permitted but once in the day, and other articles of food be selected 
with special care. Tobacco should never be allowed to male patients 



ACNE. 457 

with well-marked symptoms, and the daily general bath described in 
the preceding chapter as of importance in the treatment of acne should 
here also be prescribed. 

All gastrointestinal sources of mischief should also be set aside 
when practicable. In acne rosacea, even more than in acne simplex, 
dyspepsia and constipation are conspicuously effective factors. 

Internally, nux vomica, ergot and ergotin, ichthyol (ammonio-sul- 
phate), mineral acids and alkalies, and arsenic have been recom- 
mended. Most of these drugs are valueless in removing the symptoms 
of the disease unless their use is indicated by the general condition of 
the patient. In gouty patients blue pill and alkalies, though not of 
themselves capable of relieving the rosacea, may serve to aid the 
patient ; the same may be said of the use of iron in chloro-ansemic 
women. 

The local treatment of acne rosacea is substantially that of acne 
vulgaris. Stimulating lotions of green soap, formalin, alcohol, mer- 
curic chloride, or sulphur (Vleminckx's solution is especially service- 
able) in connection with ablutions in hot water, are of the highest 
value» In addition, the various ointments containing sulphur, resorcin, 
mercuric oxide, and iodides, and the continuous application of mer- 
curial plaster should be employed if necessary. 

One of the most effective local treatments is by employment of 
radiotherapy. Under its use the nodules and diffuse redness as a rule 
disappear rapidly (for technique, see Acne vulgaris). Telangiectases 
are not removed by the .r-rays, but yield as a rule to phototherapy. Of 
12 cases treated by us, 6 made complete recovery, and 6 were improved 
very greatly. 

Phototherapy in a similar number of cases has given equally bril- 
liant results, and is preferable to the x-rays for circumscribed areas. 
When the disorder is more extensive, the results are achieved more 
rapidly and inexpensively with the #-rays (for the technique of 
phototherapy, see page 117), 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows : 

R 



Sulphuris prsecipit., 


3j; 


4 




Pulv. camphorae, 


gr. v ; 




33 


Pulv. tragacanth., 


gr. x ; 




m 


Aq. calcis, \ 
Aq. rosse, J 


aa f gj ; 


aa 30 





M. 

Fox, of New York, applies chrysarobin in traumatical, l drachm 
(2.) to the ounce (30.) ; but this drug should be reserved for intractable 
cases, as it may produce severe dermatitis. After the production of 
these effects, however, the benefits secured may be appreciable for 
months. 

In the second stage of the disease the treatment is the same as in 
the first stage, but when all the inflammatory phenomena have yielded 
and the causes of the local congestion have been removed, the vessels 
and remaining nodules may be destroyed by single or by multiple 
puncture of each with a fine cambric needle attached to the negative 



458 INFLAMMATIONS. 

pole of a galvanic battery with six to ten elements in the circuit. This 
operation is better than the knife, and it may be regarded to-day as 
the effective method of removing blemishes produced by dilated blood- 
vessels in this stage of rosacea. The method is simple, readily exe- 
cuted, requires no anaesthetic, and is in many ways superior to other 
methods, to which resort should be had when electrolysis cannot be 
employed. Some vessels may completely be destroyed with the pro- 
duction of so slight a cutaneous cicatrix that in the course of a few 
months it cannot be recognized by the unaided eye. 

For details of this simple operation the reader is referred to the 
chapter on Hypertrichosis. For the cambric needle may often be 
substituted with advantage a fine jeweler's brooch, annealed in the 
flame of a spirit-lamp. The vessels may be entered in one or several 
places, and the operation be repeated until the last thread-like evidence 
of their existence has disappeared. The number of cells brought into 
the circuit must be somewhat graduated to the requirements of each 
case and to the locality of the skin operated upon. Fewer cells can 
be tolerated for the lip and alas nasi than for the root of the nose, the 
cheeks, or the forehead. Next in value after this operation may be 
named : 

Brushing the part cautiously with solutions of caustic potash, from 
10 to 30 grains (0.66 — 2.) to the ounce (30.) of water; and the local 
use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, 
acetum cantharidis (Taylor), sulphur iodide, or solution of mercury 
pernitrate. Before these drugs are employed, however, an effort should 
be made to produce exfoliation by spreading over the part a plaster 
made of green soap. Unna's mercurial plaster-mull is similarly 
applied. Kaposi highly recommends the solution of iodated glycerin 
employed by him in acne vulgaris (q. v.), which solution is painted 
over the part from eight to twelve times daily for three or four suc- 
cessive days, and is immediately covered with gutta-percha tissue. 

Multiple scarification of all new-growths after the manner of attack- 
ing lupus-nodules, erasion with a dermal curette or with a Braun spoon, 
and surgical ablation or decortication of tumors by ligature and knife, 
are also available. After any destructive attack upon the diseased por- 
tions of the skin soothing lotions, fomentations, or ointments should 
regularly be applied. 

Prognosis. — A favorable prognosis can be given in cases in which 
the disease occurs in its milder forms. Even in cases complicated by 
marked telangiectasis and hypertrophy the results of treatment are often 
in the highest degree encouraging. Notwithstanding the most ener- 
getic procedures, however, the vis-a-tergo of passive hypersemia, involving 
often the deeper and unassailed blood-vessels, may work its slow pro- 
gress. For women the future is in general more promising than that 
of men. With the most unfavorable prognosis, however, it is to be 
remembered that the disease is one of deformity rather than of 
physical discomfort. 



ACNE VARIOLIFORMIS. 



459 



ACNE VARIOLIFORMIS. 

(Acne Frontalis, Acne Rodens, Acne Necrotica, Acne Atro- 
phica, Folliculitis Varioliformis, Necrotic Granuloma. 
fr., mlliare scrofuleuse, folliculite cicatricielle ne- 
crotique.) 



Acne varioliformis is characterized by the occurrence over the brow, 
scalp, or other regions, of discrete, exceedingly indolent, reddish-brown, 
papulo-pustular, often umbilicated, lesions, which become covered with 
crusts, and eventually leave depressed superficial scars resembling those 
of small-pox. This disease is not to be confounded with that to which 
Bazin and other French writers once gave the name Acne varioliforme, 
viz., molluscum epitheliale (molluscum verrucosum, of Kaposi). 

The disease is relatively rare, and may be characterized by the 
development of few (but one or two) or very many lesions. In some 
instances the peripheral extension of a single papnlo-pustule may pro- 
duce a narrow annular sero-purulent chamber with a depressed firm 
centre. There is commonly a well-marked coincident seborrhcea. 

Fig, 47„ 




Acne necrotica. 

Many of the lesions are traversed by a lanugo-hair. The subjective 
sensations are slight, at times there is itching. The disease tends to 
recur and is exceedingly chronic in course. 

In exceptional cases the disorder occurs in other regions than those 
named above ; for example, over the dorsal and sternal aspects of the 



460 INFLAMMATIONS. 

trunk, about the nose, and within and about the concha of the ear, 
the interscapular region, and the extremities. In one of the authors' 
patients (the subject of the accompanying illustration) the disease left 
very disfiguring scars on the right ala of the nose. The lesions often 
are traversed by a hairy filament. In some cases the affected regions 
are invaded so thickly that the resulting scars produce a cribriform 
aspect in the integument. Occasionally the arrangement of the lesions 
is linear or is circinate. 

The variations displayed are exceptional, but worthy of note. Severe 
confluent, serpiginous, and very extensive developments of the malady 
may be seen. According to Boeck, the hue of the papulo-pustule is 
due to minute capillary hemorrhages, which later become invisible in 
consequence of tumefaction of the overlying integument. 

Etiology. — The sexes are represented nearly equally among the 
subjects of the disease, who are, as a rule, in or near middle life. The 
causes of the disease are unknown, but the microbic origin of acne 
varioliformis, together with necrotic granuloma and folliclis, is well- 
nigh established. 

Pathology. — Fordyce and Sabouraud state that the disease begins 
in the upper part of the hair-follicle, from which point it extends to the 
entire follicle and to the sebaceous gland. Various micro-organisms 
are found in the lesions, but the active agent is apparently a staphylo- 
coccus. Sabouraud l believes the disease is always preceded by sebor- 
rhoea dae to infection with his micro-bacillus. 

The histological changes are similar to those of ordinary acne except 
that the process is limited distinctly in extent and almost invariably 
terminates in a small central area of necrosis and subsequent scar- 
formation. Some of these cases may be due to the presence of the 
toxins of tubercle-bacilli. Acne varioliformis occurs in typical devel- 
opment upon the faces of the tuberculous. For further details in this 
connection, the paragraphs devoted to the paratuberculoses of the skin 
(necrotic granuloma, follicles, etc.) should be consulted. 

Diagnosis. — The lesions are to be distinguished from the syphilo- 
derm named above, from acne vulgaris, and from variola. The points 
of distinction are : the absence of fever, present and precedent ; the 
absence of other symptoms of syphilis ; the localization of the eruption ; 
and the absence of intermingled comedones and other symptoms of 
acne disseminata. The involvement of the scalp-surface is not alone 
sufficient to distinguish it, as syphilodermata and occasionally come- 
dones are visible in the scalp above the brow. 

Treatment. — As a rule the disease yields readily after the use of. 
antiseptic lotions or of ointments containing white precipitate, resorcin, 
sulphur, mercuric chloride, formalin, or boric acid, though lesions are 
likely to develop after suspension of treatment. In severe cases caustics 
or galvano-puncture may be required. Crocker employs the potassium 
iodide internally with happy results. 

1 Annales, 1899, s. iii., x.,p. 845. 



IMPETIGO HERPETIFORMIS. 461 

IMPETIGO HERPETIFORMIS. 

(Herpes Py^emicus.) 

This is a rare inflammatory affection of the skin occurring for the 
most part in pregnant women, characterized by the development of 
smaller and larger pustules in groups and productive of grave systemic 
disturbance, often terminating fatally. Knowledge of this disease is 
limited to the reports of less than a score of cases observed by Hebra 
and Kaposi in the Vienna clinic, and of a few scattered cases reported 
by others, including, in America, Heitzmann, Fordyce, Whitehouse, 
and Hartzell. Of the Vienna patients, twelve were women, and the 
most of these were in the puerperal state. Gun sett l gives abstract 
of twenty-eight cases : nineteen puerperal women, eight men, one non- 
pregnant woman. 

Symptoms. — Pinhead-sized pustules, usually closely set in groups, 
filled with an opaque or a yellowish-green fluid, are discovered upon 
the surface of the groins, the navel, the axillae, the breasts, the thighs, 
and other portions of the body. A dirty brownish-colored crust is 
formed by rupture or desiccation of these lesions, and about this crust 
single, double, or triple concentric circlets of new and similar lesions 
appear in succession, each series undergoing a similar process of involu- 
tion. The eruption thus extends until the circlets from different foci of 
origin unite, and extensive areas of the skin are involved. Beneath the 
crusts the skin is reddened, infiltrated, smooth, and covered with a 
new epidermis, moist as in eczema or exhibiting a denuded corium. 
It is never in a state of ulceration. In the course of three or four 
months the eruption is well-nigh universal, the skin being swollen, 
shining, and crust-covered, or seamed with excoriations surrounded 
by circles of pustules. Exceptionally there are multiformity of lesions 
and the occurrence of the disease in women who are not pregnant. 
The lingual mucous membrane exhibits grayish, centrally depressed 
patches, well defined in contour. Alternate rigors and febrile accesses 
mark the periods of recrudescence when new pustules form. Delivery 
seems to have no favorable effect upon the course of the disease 
in pregnant women. An endometritis with peritonitis was discovered 
post mortem in a single case. Two women only of the thirteen 
Vienna patients survived; one suffered from a relapse after several 
weeks of improvement. 

The Etiology and Pathology of the disease are necessarily obscure, 
having in view the relatively small number of reported cases. The 
relation between this rare disorder and herpes gestationis, dermatitis 
herpetiformis, and several forms of pemphigus is not determined ; but 
doubtless such exists and intermediate forms occur. Some of the re- 
ported instances of the disease are not regarded as strictly assignable to 
the affection first studied in Vienna. 

Dumesnil, Marx, and Dubreuilh 2 have examined the skin removed 
from living subjects of the disease, and have discovered dilatation of the 

1 Archiv, 1901, lv., p. 337. 

2 Annales, 1892, s. iii., iii., p. 353. 



462 INFLAMMATIONS. 

blood- and lymph-vessels with swollen endothelium and embryonic 
cells surrounding these, especially in the papillary body at the base of 
the pustules. Cocci were present in the pustules, which are always 
within the epidermis, and there was acanthosis of the palisade-layer of 
prickle-cells. Post-mortem evidences of nephritis, endometritis, and 
pulmonary tuberculosis have been recognized in different cases. 

The Diagnosis of the disease is between herpes, dermatitis herpeti- 
formis, and pemphigus. 

In herpes the purely vesicular character of the lesions and the cycli- 
cal career of the disease indicate its nature. In dermatitis herpetiformis 
there is commonly a distinct multiformity of lesions, and the subjects 
of the disorder are not, in such great preponderance, pregnant women. 
In pemphigus the size of the bulla? and their distribution in other than 
concentric groups will indicate the character of the disease. Special 
care should be taken to distinguish impetigo herpetiformis from pem- 
phigus vegetans. The locality primarily invaded is the same in both 
diseases. For details consult the paragraphs devoted to the malady 
last named. 

The Treatment is conducted on general principles, including the 
administration of antipyretics, and the local employment of alkaline or 
of carbolated baths ; starch and other dusting-powders ; anodyne, carbo- 
lated, or simple salves ; and coal-tar. The uterus should be relieved 
of its contents. 

The Prognosis is necessarily grave. 

PEMPHIGUS. 1 

(Gr. TTE/Luptt;, a bladder.) 
(POMPHOLYX. Ger., BlASENAUSSCHLAG.) 

Pemphigus is an acute or chronic affection of the skin, characterized 
by the formation of one or several well-defined, oval, rounded blebs, 
elevated or not above the level of the general surface, which may or 
may not be associated with systemic symptoms, the lesions developing 
in successive cycles of eruption. 

With respect to the question whether pemphigus should be regarded 
as the name of a distinct disease or of a group of several diseases, various 
opinions are held. At one time every dermatosis displaying blebs was 
accounted a form of pemphigus. With increasing knowledge there 
has been a greater reluctance to distinguish any disease by this specific 
term alone merely because of the presence of a bullous exanthem, and 
as a result a number of affections exhibiting bullous efflorescence upon 
the cutaneous surface have been wholly disassociated from both pemphi- 
gus and what the French term the " pemphigoid eruptions." For some 
authors there is only a chronic pemphigus ; for others, in order to 

1 Bibliography: Duhring, Cutaneous Medicine, pt. ii., pp. 449-468 (Phila., 1897); 
Brocq, La Pratique Dermatologique, t. iii., pp. 723-838 (complete bibliography) ; Spie- 
gler, Mracek's Handbuch, Bd. ii., p. 1 (bibliography) ; Grouven, Archiv, 1901, lv., p. 85, 
247, 419 (3 plates and bibliography) ; Krzyztalowicz, Monatshefte, 1903, xxxvi., p. 165; 
Unna, Archiv, 1903, lxvi., p. 248 (abstract). 



PEMPH1G US. 463 

establish a diagnosis of pemphigus, the existing lesions should repose 
directly upon the skin without exhibiting a peripheral inflammatory 
areola, or at least be the expression of a disease with periodic exacerba- 
tions in a determined career. 

In many morbid conditions of the skin bullae are present, when it is 
manifestly improper to call the disease pemphigus. For example, these 
lesions are exhibited typically in some forms of lepra, in inherited 
syphilis, often as a result of the traumatisms of insects, and of several 
infective processes. To assert that a disease is a pemphigus in one of 
its varieties, it is necessary to recognize the presence of other symptoms 
than bullae. 

Symptoms. — The distinctions respecting the bullous dermatoses 
established by Brocq are worthy of recognition. In a first class are 
included, as suggested above, the bullae which are epiphenomena of some 
malady (e. g., erysipelas). In a second class the bullae are either the 
main feature or one of the main features of a disease. The second 
class includes both the dermatoses in which the eruptive symptoms 
are not commonly of bullous type, but which become such under 
special conditions (e. g., polymorphous erythema bullosum), and those 
eruptions to which the term pemphigus is assigned by the best 
authors. 

It is to this second class, and to the last-named subdivision of the 
class, that the title is assigned in the paragraphs which follow. In this 
group are included : (a) Acute pemphigus ; (6) Pemphigus of the new- 
born ; (c) Chronic pemphigus ; (d ) Pemphigus foliaceus ; (<?) Pemphigus 
of young girls ; (/) Pemphigus vegetans, of Xeumann. 

It will appear later that at least two of the symptom-groups named 
above will eventually be included in a different category. 

It should be understood further that these are simply clinical dis- 
tinctions of value for the time being. There are doubtless other forms 
of pemphigus, some of which are named below ; and there are unques- 
tionably morbid conditions here described which may be classed later 
more appropriately with other affections. 

Pemphigus Acutus. — In this disorder the course of the morbid 
process is relatively rapid in the direction often of a grave termination 
or toward recovery, a few days or weeks sufficing for the cycle of 
manifestations. The existence of this type of malady has been denied, 
but cases are on record in sufficient number to justify the collation of 
the symptoms in a distinct category. We have had under observation 
four adults exhibiting classical symptoms of the disorder, one young 
woman dying in a week after the onset of the attack. 

There is usually a premonitory malaise with chills and fever, fol- 
lowed by the rapid efflorescence of split-pea- to small-egg-sized blebs 
symmetrically and at times very generally displayed over the body- 
surface. There is about many of the lesions a distinct halo. The 
mucous membranes, more particularly the mouth, may be involved 
slightly or extensively or be spared wholly. The eruption when devel- 
oped is accompanied by a febrile process : the systemic signs of grave 
prostration are commonly present ; the eruptive phenomena may be 
developed in cycles or in a single rapid explosion ; and the contents of 



464 



INFLAMMATIONS. 



the blebs may be pellucid, cloudy, purulent, or hemorrhagic. In fatal 
cases there are coalescence of blebs, a purulent and bloody character of 
their contents, and the denudation of large areas of the skin whence 
have been removed the outer layers of the epidermis. In cases about 
to terminate fatally there are also usually a precedent flaccidity of the 
bullous envelopes, and the symptoms of grave toxsemia (stupor, albu- 
minuria, anuria, etc.). Pernet l collated seventeen cases, the history of 

Fio. 48. 




Acute pemphigus. (Courtesy of Dr. F. V. Johnson.) 

many of which seems to point to an origin from infection with septic 
animal poison (cases occurring after bites of animals, in butchers, etc.). 
In the cases examined, a diplococcus was recognized by Demme which 
is supposed to have been the etiological factor present. 

If it be demonstrated eventually that the disease invariably has its 
origin in the infection of a trauma with septic material of animal origin, 
the affection should be assigned to another category than pemphigus. 
Children may thus be infected as well as adults, but in the former 

1 Fernet and Bulloch, Brit. Jour. Derm., viii., 1896, p. 157 ; see also Caie, Brit. Med. 
Jour., 1903, i., p. 308. 



PEMPHIGUS. 465 

event the results are not to be confused with those recognized in Pem- 
phigus neonatorum contagiosus, described below. 

Pemphigus Neonatorum (Pemphigus Contagiosus Neonatorum 
Acutus ; Pemphigus Epidemicus ; Pemphigus Contagiosus). — This 
is a disorder obviously contagious, occurring usually in epidemic form, 
and affecting newborn infants. 

The first symptoms noted are punctate and larger reddish macules 
resembling a flea-bite. These enlarge and a thin pellicle forms over 
the spot, from which later vesicles develop as large as hazelnuts. The 
lesions often burst before reaching maturity, the areola meantime 
spreading over a space with a diameter of several centimetres. After 
bursting, the areas of involvement spread with centrifugal denudation 
of the epidermis. The fluid furnished by the lesions is scanty or abun- 
dant, golden-yellow or, especially in cases that prove fatal, grayish- 
tinted. The regions affected are the abdomen, groins, axillae, nates, 
neck, genitals, inner aspect of the thighs, the flexures of the elbows 
and knees, and, to a certain extent, the face. As the disease often 
proves fatal, the symptoms of systemic disturbance in such cases are 
well marked, including inappetence, abdominal distention, vomiting, 
waterlogged condition of the lungs, cyanosis, and dyspnoea. 

The disease occurs also in milder type, the lesions being then rela- 
tively few, the areolae about the vesieo-bullae fading, yellowish crusts 
representing the desiccation of the blebs, the contents of which become 
gradually scanty. 

Maguire l and Adamson 2 have made recent interesting contributions 
to the subject. The proof of transmission of the disease to the children 
from midwives, nurses, and attendants by the medium of the hands, 
the clothing, etc., is incontestable. Maguire shows that in every fatal 
case the stump of the umbilical cord had been infected. The disease 
is without question due to transference of pus-cocci (Staphylococcus 
pyogenes aureus ?) from one individual to another. It is now gener- 
ally admitted that the affection is really an infantile form of Fox's 
impetigo contagiosa. Adamson, however, calls attention to the warn- 
ing of Sabouraud, that the staphylococcus is invariably present as the 
result of a secondary infection, and that by the use of a fluid medium 
securing anaerobic conditions the streptococcus may be recognized. 

It follows from what precedes that pemphigus neonatorum also may 
properly be removed from the category of affections strictly catalogued 
as pemphigoid. 

Chronic Pemphigus (Pemphigus Vulgaris). — The term Pemphigus 
Chronicus is applied to the more common clinical forms of the malady, 
and it has been employed generically by many authors to include all 
varieties of the disease. The title Pemphigus Diutinus has been 
used also to designate that pemphigoid eruption in which the character- 
istic lesions follow each other with rapidity and in profusion, fresh 
bullae appearing each day. Fortunately, all forms of the disease are 
relatively rare. 

The cutaneous lesions in chronic pemphigus are usually preceded by 
febrile symptoms ; and the disturbance of the economy is declared in 
1 Brit. Jour. Derm., 1903, xv., p. 427. 2 Ibid., p. 447, 

30 



466 INFLAMMATIONS. 

cardiac, respiratory, and gastrointestinal derangements of function. 
The fever may be continuous, remittent, or intermittent, and is usually 
aggravated just before the appearance of a fresh crop of blebs. 

The face, the trunk, and the extremities are chiefly involved. The 
eruption first appears bilaterally, somewhat symmetrically or asym- 
metrically, in reddish macules of rather vivid hue, in the centre of 
each of which appears later a whitish elevation of the epidermis sug- 
gesting a wheal. Either upon these or upon unaffected points of the 
skin there subsequently form tense, well-rounded or oval vesicles 
developing into bullae varying in size from that of a pea to that of a 
hen's egg and even larger, and in number from three to six only, to 
a hundred and more ; they are usually irregularly distributed (Pem- 
phigus Disseminatus), but they may be clustered in groups, or very 
rarely be found the younger encircling the older lesions, so as to form 
a circinate patch (Pemphigus Circinatus) ; their contents are serous 
or bloody (Pemphigus H^morrhagicus), or, later, purulent, the 
color corresponding with that of pus. The bulla? often coalesce, and, 
whether ruptured or not, the involution of the lesion is accomplished 
by desiccation and crusting, the crusts being usually found to contain 
blood, pus, epithelial debris, and the exudate from the base of the bleb. 
Beneath such a crust there forms a new epidermis, which is usually 
violet, purplish, or bluish red in color, and which later displays a 
brownish pigmentation which may survive the disease for several weeks. 
The evolution and involution of a single lesion may be accomplished 
within a few days, but the survival of the disease in successive erup- 
tions may extend through weeks or months. 

Occasionally the affection occurs with very mild and even insignifi- 
cant phenomena (Pemphigus Benignus). There may be no fever, 
and very few blebs appear ; in some cases but a single lesion can be 
seen (Pemphigus Solitarius). In other instances the fever is 
intense ; the eruption abundant ; the skin cedematous, painful, pru- 
ritic, excoriated ; and the underlying lymphatic glands are enlarged. 
This general condition with exacerbations and remissions may persist 
for months, and the eruption may then disappear never to return, or to 
recur, as it often does, in the future. 

Clinically, many of the distinctions between the varieties of pem- 
phigus disappear. Between the benign processes just considered and 
the grave form of pemphigus foliaceus described below several inter- 
mediate gradations can be observed, and even the most benign may at 
times unexpectedly assume the most malignant phases. Pemphigus 
Malignus is a name given generally to those intermediate varieties of 
the disease, most of which are distinguished by persistent and pros- 
trating fevers ; by cachexia, especially in infants ; by the occurrence 
of diphtheritic patches upon or about the lesions, with infiltration of 
the derma and slough of its superficial layers ; or by extensive crust- 
ing, and even subsequent ulceration. 

In all varieties of pemphigus the lesions may be exhibited upon the 
mucous membrane of the accessible outlets of the body. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and as to the period of their efflorescence. There may be a 



PEMPHIGUS. 467 

week or a month of immunity, followed by benign relapses or by ma- 
lignant and rapid recurrences. Chills, fever, gastro-intestinal disturb- 
ances, and even profound depression may precede one or each of a 
series of eruptive phenomena. The bullae may form upon an unaltered 
or a deeply hypersemic skin, in all sizes from that of a pea to that of 
an orange, invading the skin and mucous surfaces including the vagina, 
the lesions at the base exhibiting the several features described above. 
The eruption is rarely generalized, and throughout the course of the 
disease not more than half a dozen lesions may at any moment be vis- 
ible upon the surface of the skin. Their contents may be removed by 
evaporation, absorption, or rupture, leaving a crust the color of which 
is largely determined by the contents of the bleb. 

The areola, which may or may not be present in the several forms 
here described, is commonly narrow, and is fully developed only when 
the bleb is mature. The separate lesions may persist for days, or may 
rupture at an earlier period, leaving behind a superficial excoriation 
which after healing exhibits pigment. 

The intercurrent disorders in the several forms of the disease desig- 
nated may be numerous, death occurring from septicaemia, exhaustion 
(especially when a deep slough results, as in pemphigus gangraenosus), 
and lymphangitis, the neighboring vessels and glands exhibiting evi- 
dence of the toxic effects produced by the cocci present. In some cases 
the general symptoms are absent or are insignificant, and the subjective 
sensations are limited to a slight feeling of burning or of tension. In 
other cases the blebs project from the affected surface and are w r ell dis- 
tended ; in still others they are flaccid, the roof partially collapsing 
upon the serous, purulent, or bloody contents. The crusts which form 
are rarely bulky; they are more commonly dark colored and thin. 

Pemphigus Pruriginosus is a name applied to that grave form of 
the disease in which the lesions give rise to an intense pruritus. As a 
result of the scratching induced by the pruritus they are torn, exco- 
riated, and commingled with the crusts and exudations of an arti- 
ficially engendered eczema. If the itching be severe, the vesico-bullse 
may be so torn as to be difficult of recognition. Several of the malig- 
nant and intermediate forms may terminate fatally. 

Pemphigus Foliaceus (Bullous Dermatitis). — Pemphigus folia- 
ceus is a rare variety which may originate in one of the common 
dermatoses or in a grave form of pemphigus chronicus, or may, at the 
onset, present characteristic features. Hallopeau and Fournier have re- 
ported cases which began as a dermatitis herpetiformis. The lesions are 
flaccid bullae, which are developed without a perceptible preexisting ex- 
anthem, and which speedily rupture and discharge their ill-conditioned 
contents, leaving beneath an excoriated, reddish or purplish, and at 
times inflammatory surface. Often the blebs are defined so poorly that 
the epidermis seems scarcely raised from the tissue beneath, the condi- 
tion resembling that of the skin to which a blister has been applied, with 
the result of imperfect vesication. The contents, at first pellucid or lac- 
tescent, become later purulent or sanguinolent. When rupture of the blebs 
occurs, there form yellowish-brown crusts which acquire a feeble attach- 
ment to the centre of the floor of the original chamber, while the edges 



468 INFLAMMATIONS. 

remain free; these edges, visible over the affected surface, in poly- 
cyclical or irregular outlines, incompletely hiding the raw and sodden 
epidermis, present a characteristic picture. 

The disease spreads gradually until it becomes symmetrical and 
universal, a peculiarity which marks it as unique among the pem- 
phigoid eruptions, and which, in a striking degree, distinguishes it 
from pemphigus vegetans and from pemphigus acutus. As the disease 
advances the patient lies in a pitiably helpless condition, the remaining 
epidermis being completely undermined by the serum exuded, in 
places exposing large denuded areas of skin in a condition of inflam- 
mation of a low grade. Even, however, when the disease is fully 
generalized the appetite and bowel-function are at times unimpaired. 
In its later stages, after it has become generalized, the pemphigoid 
origin of the disease is not always easy of demonstration. In these 
instances large masses of greasy scales are exfoliated from the surface, 
the moisture proceeding from which is scarcely sufficient to attract 
attention. The odor from the body becomes offensive ; fissures form in 
the infiltrated skin ; the facies of the patient may become as repulsive 
as in some forms of lupus or variola ; the sweating hands with dis- 
torted nails and contractured fingers resemble claws. 

The disease affects the mouth and throat, denuding the mucous sur- 
faces of the epithelium. The scalp becomes affected, as also the covered 
portion of the body. The hairs remain attached for a long time, but 
eventually they are completely swept away. Over the face, at first 
merely reddened and scaling, occur retractive processes which at times 
produce ectropion and consequent conjunctivitis. Over the body, 
especially at points pressed upon when reclining, profound ulcerations 
may destroy the deep skin. The palms and soles are infiltrated and 
fissured rather than the seat of much exudation. The nails are com- 
monly furrowed and distorted ; occasionally they are shed. The sub- 
jective sensations are those of burning, smarting, and soreness, rather 
than of itching. If the patient be kept in the continuous water-bath, 
though the disease be not thereby ended, the comfort of the sufferer is 
admirably secured. 

There may be no fever, or there may be a rise of body-temperature 
with recurrence of lesions which, in a late stage of the disease, appear 
in the sites of those which have been very imperfectly followed by 
attempts at repair, a thin and glazed epidermis forming, in cases of 
chronic type, in the sites of former bullae. In other cases the tempera- 
ture remains above normal for weeks at a time, especially in advanced 
stages of the disease. The malady may complete its course in a few 
months or may persist for years, and though not necessarily, yet is 
unquestionably fatal in the majority of cases. Death usually results 
from exhaustion ; occasionally an intercurrent pneumonia or diarrhoea 
concludes the history. Pemphigus foliaceus commonly attacks adults, 
but Brand l reports the occurrence of the disease in a newborn child. 

The Inherited Form of Pemphigus described by Goldscheider, 
Legg, and others, most often noticed in summer, spring, or autumn, 

1 Brit. Med. Jour., June 7, 1902. 



PEMPHIGUS. 469 

rarely in winter, is considered under the title of epidermolysis bullosa 
hereditaria (see page 426). 

Pemphigus of Young Girls (Pemphigus Virginum, Pemphigus 
Chloeaticus). — This disorder, described by Hardy l and Tommasoli, 2 
is characterized by the appearance upon the skin, of oval or rounded 
spots of a reddish or rosy hue ; upon these spots there later develop 
vesico-bullse of different sizes, which speedily burst and are followed 
by the formation of thin crusts. It has been suspected that some of these 
are instances of feigned eruption (q. v.). The subjects of the disease 
are between the fourteenth and the twentieth year of life, unmarried, 
and usually menstruating irregularly. Others have described a " pem- 
phigus hystericus," to be recognized in hysterical persons of the same 
class, alternating or corresponding with hysterical attacks, the erup- 
tion not uniformly disposed over the surface, and being transitory in 
duration, disappearing with relative rapidity and leaving no cicatricial 
traces of its existence. Unna dismisses this affection from the cate- 
gory of true pemphigus. 

Pemphigus Vegetans (Erythema Bttllosttm Vegetans, Herpes 
Vegetans, Condylomatosis, Pemphigoides Maligna). — Neu- 
mann 3 in 1886 was first to describe and furnish illustrations in color 
of a disease to which he gave this name, and which has since been 
studied by a number of observers. Crocker, 4 of London, published an 
excellent monograph giving tabulated results in some eighteen cases ; 
and at the meeting in 1891 of the American Dermatological Associa- 
tion in Washington one of us 5 read a full account of the first case 
reported as such in the United States, the patient having been seen in 
connection with Duhring, of Philadelphia. Since then about fifty 
well-marked cases have been reported. 

The onset of the disease may be marked by languor, malaise, and 
ill-defined symptoms of impaired health, after which the morbid 
symptoms may first be declared in the mouth or the skin. In the 
former region white patches, which are ill-developed blebs, are visi- 
ble upon the mucous surface, which may exhale an unpleasant odor. 
The detached membrane forming each spot, finally is loosened and 
leaves behind equal-sized excoriated patches, which produce extreme 
soreness of the mouth, and which as some heal are succeeded by others. 
In severe cases they render mastication and deglutition exquisitely 
painful ; and in patients in whom this becomes a prominent feature of 
the case the nutrition of the body as a consequence is impaired 
seriously. 

The skin-lesions may precede or may follow those in the mouth. 
They commonly are seen first in women about the vulva, spreading over 
the ano-genital region and umbilicus as closely set bullae covered with 

1 Traite prat, et descript. des Mai. de la Peau, Paris, 1886, p. 268. 

2 Jour, des Mai. cutan., 1895. vi., p. 449. 

3 Vierteljahr., 1886, Band xiii. 

* Pemphigus Vegetans (Neumann), London, 1890. 

Jour. Cutan. Dis., November and December, 1891. See also Jameson and "Welsh, 
Brit. Jour. Derm., 1902, xiv., p. 287 (case, with autopsy and histology) ; Hamburger 
and Rubel, Johns Hopkins Hosp. Bull., 1903, xiv., p. 63 (case, with report on autopsy 
and histology, and complete review of literature). 



470 INFLAMMATIONS. 

a mucoid whitish secretion, the features thus strongly resembling the 
appearance of condylomata of the same region. In connection with the 
mouth-lesions, the suggestion that syphilis is present is very striking, 
and has led to this error of diagnosis in a large number of instances 
reported by those not expert in diagnosis. In other cases the scalp, 
hands, feet, axillae, and other parts are involved primarily., The bull- 
ous or vesico-bullous efflorescences, which at first resemble those of 
other forms of pemphigus, speedily exhibit at the site of their pro- 
duction, excavations, ulcerations, or more commonly vegetating masses, 
the change from the bleb to a fungoid papillomatous growth being 
scarcely appreciable. The lesions may coalesce and tend to become 
grouped about the axillae, the circle at the root of the neck, the 
bend of the elbows, the hands, the feet, and the scalp, but they have 
no tendency to become universal, even Avhen extensive. The nails 
may become affected as a result of the formation of blebs in the matrix. 
A singular change in the skin, where typical, well-formed bullae have 
developed and healed, is a deep pigmentation in puncta resembling 
comedones, with pin-point-sized verrucoid elevations of the surface. 
In some regions the sequence of the closely packed blebs, followed by 
vegetating masses, resembles that seen in pemphigus foliaceus, in which, 
especially over the back after long decubitus, there form large, granu- 
lating erosions, exquisitely painful, and conducive to a rapidly fatal 
issue. Indelible scarring may result. The disease progresses in un- 
mistakable accessions of aggravation and improvement, lasting for 
months and occasionally for years. It is in the large majority of cases 
eventually fatal. A few patients have been reported as cured. The 
authors have had two cases presenting typical features of pemphigus 
vegetans in which recovery was complete after two and four months, re- 
spectively, of treatment. In both cases, however, the eruption appeared 
a few weeks after vaccination, and was evidently the result of an acute, 
instead of a chronic, toxaemia. Variations occur, chiefly in the degree 
of febrile temperature, probably always reactive ; in the severity of 
the buccal lesions ; and in the extent of the eruption. The duration 
may be from a few weeks to two years, scarcely ever longer. 

Pemphigus of Mucous Surfaces. 1 — In almost all grave forms of 
pemphigus the mucous surfaces are involved in various degrees, includ- 
ing the lining membrane of the mouth, the vulva, the anus, the eye, 
etc. In these regions the lesions may be few or numerous, the bullae 
rounded, translucent, when unbroken slightly elevated above the gen- 
eral level, but often first subjected to examination after rupture. 
In this event one sees merely the reddened floor of the lesion from 
which the limpid or dark-reddish contents of the bleb have escaped 
or are escaping. Commonly there is a vivid areola about the mac- 
ule. After the lapse of a time the floor resembles merely a diph- 
theroid patch or a spot which has been pencilled by silver nitrate. 
The lesions of the mucous membranes as in cutaneous manifestations 
of pemphigus may be either acute or chronic ; as a rule they suggest an 
element of gravity in the cases in which they develop. Adhesions 
occur but rarely at the points where the membrane has been laid bare. 
1 Cf. Charles, Kev. hebdomad, de Laiyng., d'Otolog. et de RhinoL, 1902, xxiii., p. 337. 



PEMPHIGUS. 471 

Dermatitis Vegetans. — Under the title of Pyodermite vegetantc, 
Hallopeau x describes five cases of a disease affecting chiefly the scalp, 
axillae, genitals, groins, lips, and the mucous membrane of the mouth, 
in which there appear miliary pustules which soon are surrounded 
by a hypersernic base. The pustules appear in successive groups, 
coalesce, and the area thus formed becomes covered with crusts be- 
neath which form more or less elevated vegetating surfaces. These 
patches may increase by peripheral extension, but more commonly by 
the formation of new pustules at the border. On the mucous mem- 
branes rupture of the pustules is followed frequently by superficial 
ulcers. The disease yields readily to antiseptic treatment, leaving 
only a pigmentation which gradually disappears. Hallopeau consid- 
ered the disorder a type of local infection spreading by auto-inocula- 
tion. Similar cases have been reported under the title of Derma- 
titis vegetans, by Hartzell 2 and Jamieson. 3 AYende 4 has reported 
two similar cases occurring in children during the course of eczema, 
in both of which papulo-pustules were followed by crusts and vegeta- 
tions, chiefly on the scalp and face. He quotes other cases from 
literature, collecting 12 in all, 5 in infants and 7 in adults. In all 
there was the same type of lesions appearing in groups, the resolu- 
tion of old lesions with the appearance of new, the production of 
vegetations, and the disappearance of the disease under antiseptic treat- 
ment. The disorder is probably the result of an infection aud not 
directly related to the eczema which preceded the disease in 7 (5 
children and 2 adults) of the cases. The disorder is distinguished 
easily from pemphigus vegetans, which it resembles clinically, by the 
readiness with which it yields to antiseptic treatment, and by its failure 
to affect the general health of the patient. 

Etiology. — The causes of pemphigus are obscure ; yet the connec- 
tion of many varieties of the disease with changes in the trophic nerves 
and nervous centres is established by sufficient proofs. It is well 
known also that traumatisms and lesions of the cord have been fol- 
lowed by bullous efflorescence upon the body-surface. At the same 
time (as Kaposi has well shown), on the one hand, blebs from these 
demonstrable causes never resemble the portraits distinguishable in 
the varieties of pemphigus ; and, on the other hand, there is no uni- 
formity among lesions, either as to anatomical site or other features, 
in the spinal changes to be recognized in pemphigus with a fatal issue. 
Further, of nine autopsies of bodies dead of pemphigus examined by 
Kaposi and Weiss, in only one were changes found in the cord (diffuse 
sclerosis). The view that these dermatoses are instances of infective 
trouble (auto-intoxication) is, therefore, gaining ground, and it is quite 
probable that future investigation will demonstrate that both the cuta- 
neous and the nerve lesions are the results of a toxic agency operating 
with morbid results upon each. 

1 Archiv, 1898, xliii., p. 289 ; and xlv., p. 323. 

2 Jour. Cutan. Dis., 1901, xix.,p. 465 (with histology). 

3 Brit. Jour. Derm., 1902, xiv., p. 407. 
* Jour. Cutan. Dis., 1902, xx., p. 58. 



472 INFLAMMATIONS. 

Pemphigus is reported as of more frequent occurrence in males, but 
there is doubt as to the fact. The disease is certainly more common 
in infancy and childhood, because the powers of resistance at a 
tender age are inferior to those of a maturer epoch. It often is ob- 
served in debilitated patients who are suffering from " nervous pros- 
tration/' " mental worry and exhaustion/' " neurasthenia/' " general 
debility/' visceral disorders, and impairment of nutrition. 1 In vigor- 
ous, rosy-cheeked, strong-limbed adults the disease is rare. It is not 
inherited. The states in which there is marked impairment of bodily 
vigor are particularly favorable to the development of the disease. 
It occurs in hysteria and other neurotic affections, but the etiological 
relations which these bear to the malady are undetermined. We have 
observed one case of the disease in an adult in whom pemphigus of 
typical appearance occurred after mental depression, which was so 
greatly increased by the appearance of the exanthem as to lead to 
suicide. 

In some cases, notably in pemphigus foliaceus, it is known that 
chills and fever have preceded the outbreak. A few cases of pem- 
phigus vegetans have followed mild trauma-whitlow of the digits fol- 
lowing the wounding of the tissue with splinters. Acute pemphigus 
has followed sepsis, vaccination, rheumatic and other fevers, diphtheria, 
the exanthemata, and even long confinement in ill- ventilated apartments. 

There is good reason to believe that in some of its forms the 
disease is contagious. The bullous lesions, however, seen in syph- 
ilis, lepra, and other similar disorders should not be included here. 

The contents of the bullae of acute pemphigus were found by Gibier, 
in 1882, to contain bacteria. His observations were confirmed by 
Vidal and Roeser. Demme, 2 in 1886, found cocci both in the con- 
tents of the 'bullae and in the blood. Whiphouse 3 found diplococci 
resembling those described by Demme ; and through culture and inocu- 
lation-experiments has furnished strong presumptive evidence in favor 
of the bacterial origin of the disease. Krzysztalowicz 4 has recognized 
a streptogenous source in several unclassified forms of bullous derma- 
titis. Pernet and Bullock 5 have recorded a number of fatal cases 
which occurred in butchers, the origin of which was traced to a local 
wound-infection. Other observers have searched in vain for a specific 
micro-organism of pemphigus either in the bullae or in the blood. 

Pathology. — Anatomical changes in the spinal cord have been 
recognized in pemphigus, as explained above, but in many cases 
careful search has failed to discover such changes. Deje>ine and Leloir 
found in a case of pemphigus changes in the peripheral nerves due to 
degeneration. 

Both in the bullae and in the blood there is a marked increase (even 
to 18 per cent.) in the number of the eosinophilous cells. In this 

1 Vollmer, E., Zeitschrift, 1901, viii., 138-141 ; White, C. J., Boston Med. and Surg. 
Jour., 1903, cxlix., 297. 

2 Vierteljahr., 1886, p. 636. 

3 London Lancet, May 2, 1896. 

4 Loc. cit. 

5 Brit. Jour. Derm., 1896, viii., pp. 157 and 205 (with references to literature on 
acute pemphigus). 



PEMPHIGUS. 473 

respect pemphigus corresponds closely to dermatitis herpetiformis. The 
increase of the eosinophilous cells in both affections has been assigned 
to the effect of an irritant upon the nerve-centres ; but more recently 
these cells have been found abundantly in vesicles produced artificially 
upon the sound skin of a healthy individual, and it is doubtful if any 
especial significance can be attached to them. 

Most of the bullae are situated superficially between the rete and 
the horny layer or in the upper part of the rete, Nikolsky l believes a 
feeble coherence between the stratum corneum and the stratum lucidum 
to be characteristic of the disease. Dubreuilh calls attention to the 
intimate relationship between pemphigus and epidermolysis established 
by the facility of separation of the individual layers of the epidermis, 
congenitally bequeathed in the one case and acquired in the other. 
The bullae may be the result of an inflammation in the coriurn, but more 
probably are due to a mechanical separation of the rete-cells by a 
sudden effusion of fluid from the vessels of the derma, the papillae 
becoming at the same time markedly cedematous. Unna, describing 
chiefly the final stage of chronic pemphigus, found extensive and deep 
infiltration of vessels in the cutis. The lymph-vessels and lymph- 
spaces are dilated chiefly at the margin between the cutis proper and 
the papillary body. The ridge-net is hypertrophic, containing mitoses, 
a normal granular layer, and a horny layer varying in thickness. In 
pemphigus foliaceus the ridge-net is flattened, and the suprapapillary 
layer is reduced to a minimum, so that the altered corneous layer 
stretches almost immediately above the heads of the cedematous papillae. 
In general the cedematous epithelium is softened, and the prickle- 
borders and the interspinous spaces disappear. The epithelial cells of 
the coil-glands are swollen ; that of the ducts to a less extent. In time 
the epithelial linings of the hair- follicles disappear with the hairs. 
The entire process points to a persistent vascular paralysis, with dilata- 
tion especially of the subpapillary lymph-vessels, and an cedematous 
swelling of the constituents of the skin, denser in the connective tissue, 
and accompanied by softening of the epithelium. The hairs and seba- 
ceous glands play a purely passive part. 

In pemphigus vegetans, cultures from the fluid contained in the 
blebs are either negative or indicate the presence of Staphylococcus 
aureus. Hamburger and Rubel found Micrococcus lanceolatus in the 
lungs and a pseudo-diphtheria-bacillus in the blood of their patient. 
In most autopsies of victims of the disease no visceral changes have 
been found ; but in the case reported by Mr. Hutchinson a lympho- 
sarcomatous tumor was recognized near the spine, and in it were 
embedded the pancreas and large vessels. Hamburger and Rubel 
recognized a similar tumor riginating in the thymus and lying in the 
anterior mediastinum. 

Weidenfeld, 2 in an exhaustive study of the histology of the disease, 
calls attention to the enormous dilatation of the blood- and lymph- 
vessels always present, together with the cellular infiltration of their 
walls, the oedema of the papillary layer of the cutis, the changes in the 

1 Nikolsky, Wratscheb. Gaz., 1902 (abstr. in Archiv, 1903, lxiv., p. 452). 

2 Archiv, 1903, lxvii., p. 409. 



474 INFLAMMATIONS. 

elastic tissue-fibres, and the cedematous condition of the rete. He 
believes the dilatation of the vessels to be idiopathic and unconnected 
with epithelial changes. 

Diagnosis. — From what has preceded, it will be inferred that pem- 
phigus is a name given to a disease, and not merely to bullous lesions 
upon the surface of the skin. It is of importance to remember this 
fact, as several authors have used the term in a purely descriptive sense, 
the truth being that bullae are manifestations of several disorders, 
including syphilis, lepra, herpes iris, and erythema multiforme. 

At the outset the blebs of pemphigus can scarcely be differentiated 
from those of other diseases. It is necessary for the recognition of the 
malady that consideration be had of all the cutaneous and other phe- 
nomena present in the disease. 

In the bullae of lepra there is usually coexisting cutaneous anaesthe- 
sia, and the involution of the bleb is followed by a strikingly char- 
acteristic atrophic patch, usually pigmented and insensitive. In pem- 
phigus foliaceus the extraordinary and usually generalized desquamation 
which ensues is sufficiently distinctive, though it must be borne in 
mind that several varieties of pemphigus may be transformed, the one 
into the other, by well-nigh insensible gradations. Among its graver 
forms susceptible of such transformation may be named impetigo 
herpetiformis, pemphigus cachecticus, pemphigus diphtheriticus, and 
pemphigus pruriginosus. 

In herpes iris the lesions are more vesicular than bullous and much 
more transitory ; are concentrically arranged and vary in color ; and 
are situated more frequently upon the extremities, especially the backs 
of the hands. The bullous lesions occasionally seen in urticaria and 
erythema multiforme are to be recognized by the other characteristic 
symptoms of these diseases ; in the former, more particularly, by their 
intermingling with typical wheals, and in the latter by the location of 
the eruption and its climatic or seasonal significance. Some of the 
reported contagious forms of pemphigus, epidemics of which have been 
described by Besnier, Hervieux, and other French authors, were possi- 
bly, as Duhring suggests, instances of impetigo contagiosa. This infer- 
ence is sustained by the frequent allusion, of the writers named to the 
" varicellaform " appearance of the lesions. The lesions of true pem- 
phigus are neither contagious nor auto-inoculable. 

In syphilis blebs are rare in the adult, and relatively more frequent 
in infants hereditarily diseased. In infants the blebs usually are seen 
at birth, often upon the palms and soles, are often pus-filled, and fre- 
quently are superimposed upon an exulcerated base. The coexistence 
of mucous patches of the mouth, the vulva, and the anus with the other 
characteristic lesions and signs of grave cachexia, will indicate usually 
the nature of the disease. The cutaneous symptoms of infants thus 
affected are designated improperly as pemphigus. Such an eruption is 
a bullous syphiloderm. 

In a large proportion of cases pemphigus vegetans has been mis- 
taken for syphilis, the close grouping of the lesions about the ano-genital 
region, and their striking resemblance to condylomata, taken in con- 
nection with the presence of erosions of the mucous membrane of the 



PEMPHIGUS. Alb 

mouth, being the grounds for error. In pemphigus vegetans the vege- 
tations are more superficial than in syphilis, are of more rapid evolu- 
tion, and exhibit fringes of blebs at the border of any suspected lesion, 
while the genital condyloma has a smooth border without traces of a 
bullous efflorescence. Further, the surface is " stippled " (Neumann), 
and never smooth as in condyloma, and the mouth-lesions are far more 
painful. 

Dermatitis herpetiformis and some forms of pemphigus are " closely 
related," as Duhring suggests. The grouping, subjective symptoms, 
and even the lesions of the disorders are often alike. It is probable 
that their exact relationship may be determined eventually. However 
closely packed together may be condylomata of this region, they rarely 
spread, as does pemphigus vegetans, beyond the regions adjacent to the 
mucous outlets ; while the bullae of pemphigus vegetans, when the dis- 
ease is fairly advanced, are not only exceedingly numerous and closely 
packed together, but they spread also beyond — high toward the pubes 
and low over the inner faces of the thighs. There is commonly a 
history of fever, no lymphatic adenopathy, and a distinct uniformity 
of lesions, each separate element being of bullous type. 

Some ingested medicaments are capable of producing bullous lesions, 
for example, potassium iodide ; such a possibility should always be 
borne in mind when establishing a differential diagnosis. Scabies in 
infants and older children is occasionally characterized by the forma- 
tion of blebs, in which case the other lesions present, as also a history 
of contagion and the discovery of the parasite, will point to the real 
nature of the disease. 

Lastly, the external application of cantharides, mezereon, the stronger 
acids, alkalies, and other chemicals may be followed by blebs produced 
either by accident or by intention with a view to feigning disease. The 
intentional production of such symptoms is usually effected upon the 
anterior faces of the lower extremities, regions within easy reach 
of the right hand. Erysipelas and dermatitis calorica are also affec- 
tions in which blebs appear, always, however, of minor significance 
as compared with the other symptoms of disease present. The 
same may be said of the bullse which form upon a gangrenous integu- 
ment. 

Treatment. — The internal treatment of pemphigus is a matter of 
importance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Hutchinson 1 believed that 
" arsenic is a specific for the state of health upon which relapsing pem- 
phigus depends." This remedy should be employed, if at all, with 
caution and in accordance with the rules prescribed in the section on 
Psoriasis. Kaposi declared that he had been unable to obtain favor- 
able results from its employment. Iron, quinine, ergot, strychnine, 
and the mineral acids are indicated in many cases, in conjunction with 
a nutritious diet. Cod-liver oil and the malt preparations on the 
market should not be neglected. Salicin (Crocker), 15 grains (1.0) 
three times daily in water, has been useful. Xot infrequently the 
treatment should be directed to the relief of the anomalous performance 
1 Lectures on Clinical Surgery, London, J. & A. Churchill, 1878, p. 49. 



476 INFLAMMATIONS. 

of the sexual function in women, as pemphigus has been found to occur 
in the hysterical and chlorotic states common as a result of functional 
disorder. 

The local treatment of the lesions should consist, first, in puncturing 
each bleb with a fine needle, in order to give exit to its contents, which 
should carefully be removed from the skin with the aid of cotton-wool. 
Then the parts are to be wholly enveloped in an antiseptic wet dress- 
ing, or freely dusted with a powder, such as boric acid, zinc stearate, 
or borated talcum. When there is considerable pyrexia, with heat and 
distress in the skin, the aifected surface may be treated as an acute 
eczema, with oleated lime-water, containing opium and carbolic or 
dilute hydrocyanic acid in some such proportions as those already de- 
tailed. Weak sulphur ointments and salicylated pastes may often be 
used with advantage. 

The ordinary lead-and-opium wash, with or without the addition of 
zinc oxide, will also answer a good purpose. The continuous hot 
water-bath still enjoys among experts the highest favor in the treat- 
ment of the grave forms of pemphigus. Kaposi kept a patient day 
and night for eight months with his body thus immersed, to the great 
advantage of the invalid. This continuous bath is often impracticable 
outside a large hospital ; but in cases of grave pemphigus the continu- 
ous hot water-bath has been employed in private practice with the hap- 
piest results. 

In pemphigus vegetans internal treatment is symptomatic, usually 
along the line of elimination and support ; locally, the continuous bath 
affords speediest relief. If this cannot be obtained, the lesions should 
be cleansed thoroughly and dressed with antiseptic lotions or ointments, 
or dusted with borated, salicylated, or camphorated powders. The 
numerous scalp-lesions require cutting short the hairs of the head in 
order to make applications. Alcoholic stimulants are in most cases 
essential. 

Prognosis. — The prognosis in mild cases of pemphigus, though 
much less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the diseases 
heretofore considered, the affection is one not frequently encountered 
in persons of fair general health. The constitutional condition of the 
patient must carefully be considered ; the disease is not only one liable 
to relapses, but also is one in which the graver may succeed the more 
benign manifestations. A flaccid summit of the bleb, sanguiuolent or 
ichorous contents, an abundant efflorescence, and a rapid succession of 
new, after the involution of more ancient, lesions, are in general un- 
favorable symptoms. The same may be said of degeneration of the 
floor of the bleb after rupture and discharge of its contents. Persons 
of advanced years, the cachectic, the asthenic, and women overtaxed 
in childbearing, rarely are relieved when attacked by graver forms of 
the disease. Albuminuria, pneumonia, diarrhoea, and the inability to 
insure nutrition of the body when the mouth is sore, are all unfavorable 
complications of the disease. 



HYDRO A VACCINIFORME. 



477 



HYDROA VACCINIFORME. 

(Kecurrent Summer Eruption, Hydroa Puerorum.) 

Hydroa vacciniforme is a recurring vesicular disease, occurring 
chiefly in the summer season in the persons of young adult male sub- 
jects and solely on exposed parts of the cutaneous surface. 

This disease was described first in 1855 by Bazin and later by 
Hutchinson, Jamieson, Brooke, Crocker, 1 Bowen, 2 Graham, White, and 
others. 

Fig. 49. 



«§! 




, -10> 


w 


ifw 


l 



Hydroa vacciniforme. 

Symptoms. — The disease usually begins during the first three or 
four years of life and gradually disappears during the few years fol- 
lowing puberty. With but two or three exceptions the cases reported 
have been in boys. The disease is most active in summer, the larger 
number of patients remaining free from active manifestations during 
the winter months. The direct cause in most cases is exposure to the 
sun's rays, though exceptionally warm or cold winds, or even artificial 
heat, seem sufficient to cause an outbreak. 

The eruption is symmetrical and is limited to the uncovered parts 
of the body ; the bridge of the nose, cheeks, and ears, and the backs 
of the hands being the parts most affected. Bazin, however, reported 
cases in which covered portions of the body were slightly involved. 
The authors have under observation a case (the subject of the accom- 
panying illustration) in which a new crop of vesicles and bullae on the 
face is accompanied at times by an herpetic keratitis, the resulting scars 
interfering considerably with vision. The disease occurs in successive 
outbreaks, each of which lasts for two or three weeks. The intervals 
between recurrences in the summer may be several weeks, or so brief 



1 Diseases of the Skin, 1893. 

2 Jour. Cutan. Dis., 1894, xii., p. 81 (with review of literature, and histology). 



478 INFLAMMATIONS. 

as practically to be wanting. The lesions often are preceded by sen- 
sations of heat or itching ; and the first to appear are red macules or 
elevations, upon which rapidly are formed vesicles or bullae, varying 
in size from that of a millet-seed to that of a large pea, and occurring 
either singly or in groups like herpes ; they may coalesce and may be 
surrounded by a halo. These vesicles may dry in a day or two, or 
they may rupture and form a crust, but many of the larger become 
depressed in the centre and resemble a vaccination-vesicle. The de- 
pressed centre is black or dark blue, and is surrounded by a ring of 
fluid, while about the whole is a reddened areola. Some of the lesions 
may become purulent. The dark centre is converted rapidly into a 
thick, black crust which is very adherent, and which on falling leaves 
a depressed, reddened scar that eventually becomes white and practi- 
cally indistinguishable from that of variola. The duration of an 
individual lesion from its beginning to the formation of the crust 
is three or four days. The time required for the crust to fall is 
variable. 

The eruption usually is preceded by some slight constitutional dis- 
turbance, and by burning or pain at the site of the lesions. Itching is 
absent, as a rule, though it was marked in Bowen's case. 

Hydroa iEsTivALE, Hydroa Puerorum, Summer Prurigo. — 
A type of eruption somewhat similar in appearance, history, and eti- 
ology to that of hydroa vacciniforme, has been described by Unna, 
Hutchinson, Berliner, Graham, and others, under the names above 
enumerated. These eruptions differ from those of hydroa vacciniforme 
chiefly in being acuminate papules of a light-reddish hue with minute 
vesicular apices and other symptoms eczematous in nature. Itching is 
commonly present; macules and papules are more numerous than the 
vesicles, which are not umbilicated ; and scarring is comparatively 
slight. The disease is found in girls, though less frequently than 
in boys. 

Etiology. — Exposure of sensitive skins to the sun and wind, espe- 
cially in the summer season, is the effective cause. We have observed 
patients in whom the disease was developed not merely in summer, 
but in winter when the sunlight was reflected from snow on the 
ground. 

The Pathology has been studied by Bowen in two lesions taken 
from a single patient, and by Mibelli. 1 In the primary stage Bowen 
found merely vesicle-formation in the middle layers of the rete. In a 
more advanced lesion he found necrosis involving the lower layers of 
the stratum corneum, the entire rete, and the corium nearly to the sub- 
cutaneous tissue. He concluded that the process begins as an inflam- 
mation in the epidermis and upper part of the corium, followed by 
vesicle-formation in the rete, and later by the necrosis described above. 
The necrosis is sharply circumscribed, and, showing through the vesicles 
above, produces the black centre of the advanced lesions. Bowen 
further calls attention to the points of similarity between this disease 
and those of acne necrotica, or of acne varioliformis. 
1 Monatshefte, 1897, xxiv., p. 87. 



EPIDERMOLYSIS BULLOSA HEREDITARIA. 479 

The Diagnosis is from erythematous lupus, pemphigus, erythema 
bullosum, and dermatitis herpetiformis. The limitation of the lesions 
to the exposed parts of the body, the presence of vesico-blebs, and the 
scarring, in connection with the age of the patient, all point to the 
nature of the malady. 

The Treatment is unsatisfactory. To prevent recurrence the patient 
should be guarded from exposure to the sun and in some cases from hot 
or cold winds. Veils and coverings which exclude the light may be of 
service. Crocker recommends treating the eruption by opening the 
vesicles and applying iodoform in powder or in solution in ether. After 
removing the crusts with carbolized oil the surfaces may be dressed with 
an ointment containing iodoform and boric acid. 

The Prognosis is unsatisfactory, as until adult years are attained 
the patient is liable after fresh exposure to recrudescence of the disease. 

EPIDERMOLYSIS BULLOSA HEREDITARIA. 

(ACANTHOLYSIS BULLOSA.) 

This name has been given to a rare affection or condition of the skin 
in which there is a pronounced tendency to the rapid formation of bullae 
wherever the integument may be slightly bruised or rubbed. Cases 
have been reported by Goldscheider, Kobner, Valentine, Elliott, 1 Beatty , 2 
Bowen, 3 Wende, 4 and others. 5 In the majority of cases reported the 
condition had existed from infancy or early childhood, and there was 
a clear history of heredity. Valentine reported eleven cases which 
occurred in four generations of the same family. 

The general health of individuals thus affected may be excellent and 
the skin remain sound so long as it is subjected to no irritation, but in 
some cases very slight causes (the pressure of a shoe in walking ; the 
grasping of a firm substance, such as the handle of a hammer ; the 
friction of suspenders or waistband) are sufficient to cause the appear- 
ance of firm, tense, blebs at the site of the irritation. Such bullae 
vary in size from that of a small pea to that of a walnut. They 
often last some days, having a firm roof-wall ; are usually more or 
less painful, especially after rupture ; and disappear without leaving 
either pigmentation or scar. The predisposition to the formation of 
new bullae, however, remains indefinitely. In Bowen 's case the bullae 
were often hemorrhagic in type and were followed by pigmentation 
and scarring. 

Histological studies of the lesions have thrown little light on the 
etiology and pathology of the process. Elliott examined portions of 
apparently normal skin from one of his patients, and found in all the 
sections a granular degeneration of the basal layer of rete-cells and fre- 

1 Jour. Cutan. Dis., 1895, xiii., p. 10; Ibid., 1899, xvii., p. -539 ; and X. Y. Med. 
Jour., April 21, 1900. 

2 Brit. Jour. Derm., 1897, ix., p. 301. He gives a resume of all previously reported 
cases. 

3 Jour. Cutan. Dis., 1898, xvi., p. 253. 

4 Ibid., 1902, xx., p. 537 (recent bibliography), and Ibid., 1904, xxii., p. 14. 

5 For complete bibliography, see Luithlen, Mracek's Handbuch, i., p. 737. 



480 INFLA MM A TIONS. 

quently of adjoining cells. The changes were most pronounced in the 
interpapillary portions. This condition permits a serous effusion to 
separate rapidly the rete from the papillary body and produce bullae. 
Elliott suggests that the disease is due to an excessive irritability of the 
cutaneous vascular supply, which responds to such slight stimuli as 
ordinary friction of clothing. The lower rete-cells are in consequence 
constantly bathed in more or less serous transudation, and degeneration 
results. 

No treatment has been found capable of insuring relief. 



CLASS III. 
HEMORRHAGES 



PURPURA. 

(Gr. TTop(j)Vf)t:oi- } purple. ) 



Hemorrhage into the skin may result from undue intravascular 
pressure, as in violent effort with extraordinary demand upon the circu- 
latory system. It may occur with a normal intravascular pressure 
when there is lessened extra vascular atmospheric pressure, as after ordi- 
nary exertion in high altitudes. It may result from disease of the 
vascular walls (as in malnutrition). It may result also from lack of 
support of the vessels due to various disorders of perivascular tissues, 
as where the epidermis is artificially removed, or where an abscess-cavity 
is evacuated of pus and the sac immediately fills with blood. It may 
be due to traumatism of the vascular wall. The discolored patches 
which result from contusions of the surface of the body are illustrations 
of this condition. It occurs most frequently, however, as a result of 
visceral disorders, and undoubtedly is due to the presence in the blood 
of some infectious or toxic agent which acts directly on the vessel-walls. 

Purpuric eruptions occur in many and varied constitutional condi- 
tions. They are seen in the course of measles, scarlatina, variola, 
malaria, 1 typhoid, and other specific fevers ; in septicaemia ; in tubercu- 
losis ; 2 in sarcoma and lymphadenoma ; 3 in toxaemias, including those 
due to the iodides, bromides, copaiba, belladonna, quinine, and other 
drugs, or to other articles against which the individual has an idiosyn- 
crasy or which he does not properly digest and assimilate ; in rheumatic 
and gouty disorders ; in the cachexias of renal, tubercular, malignant, 
and other diseases ; and in functional and organic disorders of the ner- 
vous system. 

In short, purpura occurs in such a variety of conditions that it must 
be considered as a symptom of these conditions, and not as a distinct 
disease. Moreover, its relation to these constitutional disturbances is 
not well understood, and a satisfactory classification of the different 
forms of purpura based upon their etiology or pathology is not possible. 
As a matter of convenience the cutaneous hemorrhages are grouped 
according to the predominating symptoms into simple, rheumatic, and 

1 Cf. Engman, Jour. Cutan. Dis., 1903, xxi., p. 489 (with bibliography). 

2 Cf. Cohn. Munch, med. Wchnschrft., 1901, xlviii., p. 2001. 

3 Cf. Herringham, Brit. Jour. Derm., 1903, xv., p. 187 (abstract). 

31 481 



482 HEMORRHAGES. 

hemorrhagic purpuras. These groups are not sharply divided, however, 
but merge the one into another. 1 

Symptoms. — The lesions of purpura have the following character- 
istics in common : They all are due to escape of blood into the tissues ; 
they do not fade under pressure ; they usually appear suddenly ; at first 
they are of a bright- or deep-red color, which in a few hours or days 
changes to the duller and darker shades of red, purple, and brown, 
which in turn, beginning at the centre, slowly fade through various 
shades of brown, green, and yellow to the normal color of the skin. 
On the lower extremities the pigmentation sometimes persists for years. 
According to their shape, size, and arrangement, the lesions of purpura 
are designated as petechia which are pin-point- to small coin-sized, 
usually well-defined macules, sometimes situated about the hair-follicles ; 
ecchymoses, which are like petechia?, except that they are larger and 
more irregular in shape and in distribution, sometimes covering the 
entire surface of a limb ; and vibices, which are linear and band-like 
arrangements of ecchymoses. Occasionally the hemorrhage takes the 
form of bullae (bull^) hemorrhagica), or of nut- to egg-sized, and 
even larger, tumors (ecchymomata). At times purpura is seen in the 
form of minute papules. In addition to the clinical forms above 
described, purpura may appear as a complication and modification of 
the various lesions of erythema multiforme, urticaria, and other cuta- 
neous diseases. The disorder may be recurrent or even persistent. 
Osier 2 reports a case of purpuric erythema, of eight years' duration, 
associated with pigmentation of the skin and enlargement of the liver 
and spleen. 

Purpura Pulicosa is the result of the traumatisms produced by 
fleas, lice, and bugs. The lesions are punctiform and are due to the 
welling up of blood into the minute punctured wound, which is sur- 
rounded usually by a hypersemic halo, the result of the irritation. 
When the areola fades the central hemorrhagic point usually persists 
for a brief time. The disease is characteristically manifested upon the 
filthy skins of individuals long bitten by bugs and covered with 
excoriations and dark-colored crusts the result of scratching. Such 
cases are often pronounced scorbutic. 

Purpura Simplex. — In this form of cutaneous hemorrhage, pinhead- 
to pea-sized, light-red to dark-purple petechia? and small ecchymoses, 
usually multiple and symmetrical, a few at a time or suddenly in 
large numbers, appear upon various portions of the body-surface, 
chiefly over the lower extremities, and here doubtless by preference 
because of the greater effect of gravity upon the column of blood. The 
lesions usually awaken no subjective sensation, and they may occur in 
persons of apparently unaltered health, though rigid examination will 
often disclose some facts having a bearing upon the etiology of the dis- 
ease. The subjects of the disorder may be asthenic, and complain of 
unwonted lassitude and malaise. The disease may last for a fortnight, 
and in exceptional cases may be accompanied by a rise of temperature. 

1 Of. Oddo and Olnier, Arch. gen. de. med., 1900, iii., pp. 138 and 331 ; Torok, 
Jour. Mai. cutan., 1903, xv., p. 251. 

2 Jour. Cutan. Dis., 1903, xxi., p. 297. 



PLATE VIII 







Purpura Due to Copaiba. 

(From a painting ) 



PURPURA. 483 

Lesions of this sort may be due solely to an ingested medicament, such 
as arsenic, salicylic acid, or quinine. The lower extremities may be 
covered completely with petechia? induced by ingestion of potassium 
iodide. 

Purpura Urticans is that form in which there is an irritability of 
the skin sufficient to produce wheals and other urticarial lesions that 
are accompanied by itching in various degrees and that have a pur- 
puric hue in consequence of circumscribed cutaneous hemorrhage. 

Purpura Rheumatica (Peliosis Rheumatica, Arthritic Pur- 
pura, Schonlein's Disease). — This variety of purpura, which has 
a striking analogy to erythema multiforme, is probably an exaggerated 
form of some of the conditions recognized under that title. It is pre- 
ceded by the usual febrile or other premonitory symptoms associated 
with arthritic pains, especially of the knees and ankles, which may 
become swollen or be affected with a hydrarthrosis. In a few days 
petechial to ecchymotic, light-red to dark-purplish maculations appear 
upon the extremities, the trunk, or the entire surface of the body, fade- 
less under pressure, and usually with coincident relief of the arthritic 
pain. The subjective sensations are ordinarily trivial. In a fortnight 
the eruption may subside, its color undergoing the usual variations 
from greenish to orange and light yellow; but relapses are common in 
the course of weeks, with recrudescence of the fever, return of 
rheumatoid symptoms, and progressive asthenia. The purpuric spots 
sometimes make their appearance regularly in the afternoon or evening, 
sometimes daily and often with several days' interval, accompanied by 
pain, stiffness, and swelling of joints. The arthritic symptoms are 
extremely variable and may be slight or severe. While most common 
in the knees and ankles, they may appear in any joints of the body. 
Associated with the purpura and the arthritic symptoms there are often 
mild or severe gastro-intestinal disturbances. 

There are thus, in the majority of cases, three groups of symptoms, 
the cutaneous, the arthritic, and the gastro-intestinal. It is rare, how- 
ever, for these symptoms to be equally severe in any one case, one or two 
of the groups being usually but slightly or not at all apparent. Fre- 
quently one group follows another. Thus, the arthritic pains may sub- 
side before the appearance of the purpura, or the reverse may be true. 
Throat-lesions, acute circumscribed oedema, 1 and urticaria are often 
seen with one or more of the groups of symptoms above described. 
The intimate relation of purpura rheumatica to erythema multiforme 
is discussed in the pages devoted to the latter disorder. Cases are 
described in which there was coincidence of purpura rheumatica with 
renal hemorrhage, albuminuria, and gangrene of the soft palate. Cases 
are also on record in which there were cardiac involvement and grave 
disorders of other viscera. 

The disease occurs in both sexes, though more often in young 
women, and is to a certain extent influenced by the changes of climate 
and season. Its diagnosis, in consequence of its marked characteristics, 
coincidence of petechia? and ecehymoses with rheumatoid pains, is 
effected readily. Duhring calls attention to the danger of confounding 
1 Cf. Bowen, Jour. Cutan. Dis., 1892, x., p. 434 (references to literature). 



484 HEMORRHAGES. 

the disease with the macular syphiloderm, the lesions of which, how- 
ever, when relatively recent, fade under pressure. 

The prognosis is in general favorable, though the condition may 
persist for long periods of time, and may, in rare cases, terminate 
fatally. The final result depends naturally upon the constitutional 
affection with which the purpura is associated. 

Purpura Hemorrhagica (Morbus Maculosus Werlhoffii; 
" Land-scurvy "). — This disorder is usually ushered in with phe- 
nomena of a febrile character, accompanied by symptoms of general 
depression. Subsequently ecchymoses appear upon the extremities and 
the trunk, both spontaneously and at points at which the integument 
has specially been subjected to pressure and friction. Often petechia? 
appear simultaneously upon the nasal, laryngeal, buccal, and other 
mucous surfaces, which may also be the seat of exhausting hemor- 
rhages, resulting rarely in fatal collapse. A symptomatic fever is 
usually awakened. The disease occurs equally in the robust and the 
feeble of all ages, and, though commonly a sporadic affection, it may 
assume an epidemic form. Purpura hemorrhagica is slow in its course, 
but, as a rule, terminates favorably after the lapse of several months. 
In some instances the general symptoms are those of typhoid fever ; and 
hemorrhage from the mucous surfaces, including those of the stomach 
and intestines, may be severe. In yet severer cases, to which the name 
Purpura Fulminans is applied, the symptoms are those of septicemia 
or of other acute and severe infection. In these cases extensive internal 
hemorrhage may be followed by death. Little l reports a series of cases 
in infants with a rapidly fatal termination and associated with hemor- 
rhage into the suprarenal capsules. Many of the severer cases of 
hemorrhagic purpura undoubtedly are due to infections the exact nature 
of which is not understood. 

The lesions commonly appear first on the upper extremities, then 
over the trunk, and finally over the lower extremities. They are 
usually dark red or purplish in hue, varying in size from that of a pin- 
head to that of a bean, but they may be of the size of the palm. 

Hemorrhagic purpura is distinguished from purpura scorbutica, or 
" scurvy," by the absence of distinctive premonitory symptoms of the 
latter disease which always occurs among those suffering from improper 
alimentation, vitiated air, and lack of exercise. 

Purpura Scorbutica (Scurvy). — This disorder is peculiar to those 
who are compelled to subsist for lengthened periods of time on improper 
diet, more particularly that from which fruit and fresh vegetables are 
excluded; to respire vitiated air; and to endure such confinement as 
precludes the possibility of duly exercising the body. The disorder is, 
hence, more common among sailors, prisoners, Arctic voyagers, and men 
similarly situated. 

The cutaneous lesions are, as in so many other forms of purpura, 
preceded by an almost characteristic sense of languor and depression. 
One or several joints may then enlarge. There may be a distinct 
febrile action. 

The hemorrhages which result resemble those of purpura hsemor- 

1 Brit. Jour. Derm., 1901, xiii., p. 445 (with bibliography). 



PURPURA. 485 

rhagica ; the cutaneous lesions are petechia?, ecchymoses, and painful 
ecchymomata, usually first appearing on the lower extremities, that 
may fluctuate, open, and result in offensive ulcerations reaching to the. 
bone. Simultaneously with the cutaneous eruptions the gums become 
involved, showing tumid, hemorrhagic, or ulcerative fungosities, 
smeared with a dirty yellowish secretion, and having a fetid exhalation. 
The subcutaneous connective tissue, muscles, fascia?, and viscera become 
involved. The disease is accompanied by febrile and other general 
phenomena of asthenia, and, when the causes are persistent, results 
fatally. It is, however, remediable by proper treatment, though con- 
valescence usually is prolonged tediously. 

Haemophilia is a disease occasionally of hereditary origin, charac- 
terized by the facility with which trivial traumatisms of the body- 
surface are followed by incoercible hemorrhages ; purpura may be the 
first signal of the predisposition. A young man with purpuric lesions 
of both lower extremities, but otherwise apparently in good health, 
presented himself at the dermatological clinic. There Avas at the time 
no suspicion of haemophilia, but two weeks later as the result of a vac- 
cination he bled continuously for eight days. 

Etiology. — The causes of purpura vary with the constitutional dis- 
turbances upon which it depends. Direct infection is undoubtedly the 
cause of many hemorrhagic purpuras. Letzerich, in 1889, recognized 
in the spots of purpura hsemorrhagica long bacilli, cultures from which 
injected into rabbits produced a purpura with stuffing of the hepatic 
capillaries by colonies of the same micro-organism. Other investigators 
since, have tound various micrococci or bacilli in the lesions of purpura 
haemorrhagica or in the blood. Some of these organisms have been 
cultivated and the disease reproduced in rabbits, dogs, and guinea-pigs 
by inoculations with pure cultures. The purpuras occurring in typhoid 
and other specific fevers evidently are due indirectly to infection. The 
majority of the purpuras are, without doubt, infectious or toxic in 
origin. 

The influence of the nervous system in the origin of some purpuras 
is unquestionably important. Purpura may occur in the course of 
various functional and organic disorders of the nervous system. It 
has followed severe neuralgia, over-exertion, sudden fright, a fit of 
anger, and other violent emotions. By many authors the rheumatic 
purpuras are considered neurotic in origin. Osier suggests that the 
purpuras, together with urticaria, angioneurotic oedema, and erythema 
multiforme, may depend upon "some poison — an alkaloid, possibly 
the result of faulty chylopoietic metabolism, which in varying doses in 
different constitutions excites in one urticaria, in a second peliosis rheu- 
matica, and in a third a fatal form of purpura." 

Pathology. — The hemorrhage occurs chiefly in the corium, but also 
at times in the subcutaneous tissue. The corium shows collections of 
red blood-corpuscles, and later variously sized granules of blood-pig- 
ment which is slowly absorbed, producing the color-changes character- 
istic of purpura. The pigment may be wholly absorbed in a few weeks 
or persist for years. Evidences of inflammation are present in some 



486 HEMORRHAGES. 

cases, there being dilatation of the papillary vessels, with some oedema 
and perivascular infiltration of leucocytes. In a few instances endo- 
thelial proliferation and endarteritis have been noted. 

Wilson, Fox, and others have recognized lardaceous or inflammatory 
changes in the vascular walls, with embolism or thrombus in others. 
Watson Cheyne 1 and others have found some of the capillaries in the 
neighborhood of the hemorrhages plugged with bacilli, and colonies of 
the same in the effused blood. Leloir found in a single case coagulated 
fibrin adhering to the walls of a number of vessels of the skin. 

Examinations of the blood have shown irregular variations from 
normal in the number and form of the blood-cells and in the quantity 
of fibrin. Micro-organisms have been found in many cases. These 
examinations, however, have not thrown much light on the pathology 
of purpura. 

Treatment. — The treatment of these various forms of cutaneous 
hemorrhage depends upon the nature of the cause in each case. If 
this be found and removed, no other treatment may be necessary. In 
general it may be said that internally the use of ergot, of ferric chloride 
or other salt of iron, and of quinine is advisable. Oil of turpentine, 
plumbic acetate, and dilute sulphuric acid have all been employed at 
times with marked success, at others without avail, in the treatment of 
these cases. Hypodermatic injections of ergotin, 1 part to 2 of dis- 
tilled water, repeated every second day, have been followed by favor- 
able and rapid results. A generous diet, the use of wine, malt liquors, 
and even spirits, and a strict observance of the demands of hygiene, 
are often essential methods of relief. 

In the way of local treatment the gums often require an application 
of rhatany, 1 part of the extract to 50 or 60 of lotion ; or equal parts 
of tincture of cinchona and tincture of myrrh, diluted as required. 

Rest in the recumbent position is advisable, and in severe cases is 
imperative. If hemorrhage be actually in progress, the free use of 
haemostatics will be required, with local application of ice. For those 
who are convalescent from systemic disorders accompanied by purpuric 
lesions of the lower extremities, resorption of the extravasated blood 
may be hastened by the local application of stimulating spirit-lotions 
with friction ; and the pressure of the blood-column may partly be 
relieved by elastic bandaging of the extremities. 

The Prognosis has been given, as far as might be, in connection 
with each disorder named. 

1 Brit. Med. Jour., 1883, i., p. 416. 



CLASS IV. 
HYPERTROPHIES. 



LENTIGO. 

(Lat. lens, a freckle.) 

(Freckle, Ephelis. Ft., Ephelide, Lentille; Ger., Sommer- 

SPROSSE.) 

Symptoms. — This condition is due to excessive and irregular de- 
posit of pigment in the skin, producing the pinhead- to bean-sized 
spots of circinate or of irregular outline, frequently grouped and even 
confluent, which spots are commonly designated as " freckles." They 
are most frequently seen symmetrically distributed on those parts of 
the body ordinarily exposed to the light and heat of the sun and to at- 
mospheric influences, such as the face, the neck, and the backs of the 
hands in persons of both sexes. In those individuals whose bodies 
are to a greater extent similarly exposed they occur upon the chest, the 
back, and over the extremities. In other persons they may be seen 
upon parts not thus exposed, such as the penis, the scrotum, and the 
inner surfaces of the thighs, a fact which indicates that freckles are not 
always the result of the operation of the agencies noted above. They 
vary in color from light yellow, salmon, or red to the deepest brown ; 
and are most noticeable in those having red hair and a delicate skin. 
Freckles occur rarely in infancy, partly, perhaps, on account of the 
infrequency of outdoor exposure in tender years. They are usually 
seen first about the age of six to eight years. They are commonly 
observed in mulattoes, individuals of a race particularly disposed to 
anomalies of pigment-distribution. Once developed, the lesions may 
persist through life without marked alteration ; or may fade with each 
recurrence of the season of winter ; or in milder cases may disappear. 
They usually share in the atrophic changes of old age, and, when per- 
sisting to that period, may then spontaneously disappear. They are 
not the source of subjective sensation. 

Etiology. — Freckles are unquestionably produced and aggravated 
at times by the action of the light and heat of the sun, as common ex- 
perience suggests ; but it is evident that these forces must act upon a 
susceptible skin. Of a hundred sailors exposed in precisely similar 
situations on a long cruise, some of the number will uniformly be 
" tanned " and others deeply " freckled." Attention has been called 
to the occasional occurrence of lentigo in the protected parts of the 
skin. Exposure to sea-air and fog, with obscuration of the sun, is suf- 
ficient to produce the result. 

487 



488 HYPERTROPHIES. 

Pathology. — Freckles are due to an increased deposit of pigment 
in definite areas of the rete mucosum of the epidermis, never in the 
corium. The pigment accumulates densely in and about the prickle- 
cells, which become apparently softer and lose their spines at a later 
stage. Unna divides pigmentations of the skin into two classes : 
hemosiderosis (due to granules containing iron) ; and melanosis (due 
to pigments in which the presence of iron has not been determined). 
In lentigo no iron-reaction has been recognized. Lassar urges, with 
strong probability, that there is always a congenital predisposition to 
these pigment-formations that requires certain external conditions for 
development. 

Treatment. — The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Wertheim, of Vienna, advises : 

R Hydrarg. ammon. muriat., gr. lvj ; 3 75 

Bismuth, magister., gr. lij ; 3 50 

Ungt. glycerin!, Bj ; 30 [ M. 

Sig. To be applied every other night. 

Bulkley employs : 

B Hydrarg. chlor. corros., gr. vj ; 4 

Acid, acetic, dilut., f^ij ; 8 

Boracis, 9ij ; 2 66 

Aq. ros., fgiv; 120 M. 

Sig. To be applied night and morning, at first with gentle brushing ; after- 
ward by rubbing. 

Hardaway touches each freckle with a rather stiff needle connected 
with the negative pole of a galvanic battery, and he finds the results 
satisfactory. 

Most of the methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, it is 
evident that the pigment of its cells is also removed with it, and the 
new epidermis is for a time free from blemish. But in all such cases 
the ultimate result is a deeper and more persistent pigmentation than 
that which was previously visible. 

CHLOASMA. 

(Gr. x^oaw, to possess a greenish color.) 

Symptoms. — In this affection the skin is either diffusely discolored 
in various shades, or the maculations occur in patches larger than 
those of lentigo, fairly well defined, and irregular in contour, the so- 
called " liver-spots." In color they vary from a scarcely perceptible 
staining of the skin that requires a strong light for its detection, to a 
deep-yellow, a yellowish-green, a chocolate-brown, or a blackish shade 
(Melanoderma). They may be idiopathic or symptomatic in 
character. 

The idiopathic varieties of chloasma are produced by all externally 
operating agencies, in consequence of which an undue afflux of blood 



CHLOASMA. 489 

is persistently determined to any portion of the skin. It is largely 
from the blood that the pigment is derived, hence the stains produced 
by the pigment are, to a certain extent at least, proportioned to the 
hyperemia, stasis, or extravasation of the vascular fluid. Among these 
externally operating agencies may be named pressure and friction (as 
over the part covered by the pad of a truss) ; traumatism (as after the 
severe scratching of the skin affected with lice, eczema, or scabies) ; 
heat (as in diffuse " tanning " of the face, or " sunburn " following 
exposure to the solar rays) ; and the toxic or irritating effect of externally 
applied substances, such as mustard, capsicum, cantharides, and other 
articles capable of producing either vesication or pustulation of the 
skin-surface. Persistent or even permanent pigmentation of the skin 
upon the face, shoulders, and bosom, especially of young women, may 
be produced by the repeated application of such topical medicaments. 

The symptomatic varieties of chloasma are the result of disorders 
either systemic or those involving the internal organs. They occur as 
either circumscribed or diffused, localized or generalized, spots, mot- 
tlings, stainings, or " masks " of the skin, and they vary in color from 
the lightest to the darkest shades. One of the most common, and at 
the same time the most marked of these varieties, is 

Chloasma Uterinum, so called because of its frequent association 
with certain physiological or pathological conditions of the uterus, both 
among married and single women. Thus, in pregnancy, sterility, hys- 
teria, chlorosis, ovarian disorders and tumors, and functional derange- 
ments of the uterus there can be observed at times a facial discoloration 
extending equably over the forehead and reaching nearly to the line of 
the hairs at the scalp, in the form of a faint or a decidedly reddish-yellow 
or deep-brownish tinge. At other times the discoloration is macular 
and asymmetrical, involving the eyelids, the cheeks, the lips, or the 
chin. When the chloasma assumes the mask-like form it is usually 
most pronounced over the forehead, but it may involve the whole facial 
region, being less distinctly defined below than above. Similarly, the 
well-known changes occur in the areola of the nipple, along the linea 
alba, and about the external genitalia. 

Chloasma (or Melanoderma) Cachecticorum is another of the 
symptomatic pigment-disorders, characterized by changes in the color 
of the integument of the subjects of tuberculosis, syphilis, cancer, 
chronic alcoholism, malaria, and other disorders. Its hue varies between 
a faintly defined yellow to a deep chocolate. 

Addison's Disease, formerly thought to be due exclusively to 
lesions of the suprarenal capsules, is of the same nature, and is charac- 
terized by a peculiar bronzing of the skin. Overbeck and Greenhow 
have shown that the capsules may be destroyed wholly without 
changes in the skin-color resulting. The pigmentation may be gen- 
eral or be partial, and in the latter case is without definite lines of 
demarcation. It is commonly most pronounced over the face and neck, 
the scrotum, the groins, the axilla, and the nipple and areola. The 
hairs become coarse and dark ; and dark or grayish-brown patches are 
at times visible over the mucous surface of the lips, the gums, and 
other parts of the mouth. The bronze or mulatto-like color of the 



490 HYPERTROPHIES. 

skin is intensified by stimulation or erosion of the cutaneous surface, 
and by exposure to light. In these cases there are generally marked 
asthenia and a feeble pulse, with anorexia and other signs of gastro- 
intestinal disorder. When the result is fatal there may or may not be 
recognized pathological alterations of the suprarenal capsules. 

The pigment when examined furnishes no iron-reaction. 

Hadra, of Berlin, reports a case of Addison's disease cured by extir- 
pation of a small apple-sized tubercular neoplasm of the retroperitoneal 
glands. A suprarenal capsule was contained in the growth. 1 

In Graves' disease 2 there may be freckle-like, patchy, or diffuse 
pigmentation of the skin, usually most marked in regions which have 
normally more pigment than the general surface of the body. 

Among the cutaneous disorders capable of producing skin-pigmenta- 
tion may be named scleroderma, lepra, angioma pigmentosum et atroph- 
icum, eczema (especially e. venis varicosis), and general exfoliative 
dermatitis. 

From all the- above-named discolorations, which are due solely to 
deposition in excess of coloring-matters normally existing in the skin, 
it is necessary to distinguish the various dyschromia which are owing 
to the introduction into the integument of coloring substances, either 
supplied by other portions of the body or foreign to it. Thus, in 
Icterus the bile may color the skin from a light-yellow to a dark- 
chrome shade, the duration and severity of the cutaneous symptoms 
depending upon the nature and gravity of the hepatic disease. This 
condition is frequently accompanied by pruritus in various grades of 
severity, the exact causes of which are obscure. 

Chloasma from Ingestion of Arsenic. — The administration of 
arsenic in full doses for relief of nervous disorders in adults and chil- 
dren is frequently followed by a characteristic dull-brownish or dirty- 
colored discoloration of the skin of the neck and chest. In connection 
with these arsenical pigmentations, which are in some instances obsti- 
nate and generalized, may occur palmar or plantar keratoses, as well 
as those appearing elsewhere, which may be the starting-point of an 
epithelioma. 

Argyria. — A bluish, bluish-gray, slate-colored, or bronzed colora- 
tion of the skin may result from ingestion of silver nitrate. Argyria 
is most commonly the result of the administration of the drug in the 
treatment of epilepsy, but it is said to have also resulted from the topi- 
cal application of silver-crayons to the throat, to the conjunctivae, and 
even to the skin. Under what form the silver produces this effect, 
whether as an albuminate or other salt, is not known. The deposition, 
however, occurs in the form of minute particles of the metal in the 
connective tissue of the derma. The discolorations are most evident 
upon the parts of the skin exposed to the light, as the face and hands ; 
but the chest and the lower extremities may be stained similarly. The 

1 Med. Week, 1896. 

2 For a review of the cutaneous changes seen in Graves' disease with bibliography, 
see Dore, Brit. Jour. Derm., 1900, xii., p. 353 ; and Hyde and McEwen, Amer. Jour. 
Med. Sci., 1903, cxxv., p. 1000. 



CHLOASMA. 491 

connective tissue of the viscera is at times also involved, showing thus 
that the action of light is not essential to the production of the dys- 
chromia. Two cases are reported as relieved by the administration of 
potassium iodide. 

Tattooing. — By the process of tattooing mineral and vegetable 
substances are directly introduced into the corium by means of needles, 
for the production in the skin of various devices in colors. Individuals 
whose entire integument has been thus artificially covered with figures 
of different patterns by tattooing with indigo, vermilion, and cinnabar, 
are from time to time publicly exhibited. The results are indelible. 
Post mortem these pigments have been discovered not only in the 
derma, but also in the lymphatic ganglia nearest the site of their 
introduction. 

Anomalous Discoloration of the Skin and the Mucous 
Membranes. — Bruce 1 describes the case of a harness-maker, the gen- 
eral surface of whose body, especially the skin of the face and of the 
extremities, as well as the mucous surfaces, underwent a noteworthy 
change of color. The hue acquired was a deep and uniform cyanotic 
shade. The symptoms in this case are believed by some to have resulted 
from the employment of nitrate of silver. 

Pathology. — The lentigines, ephelides, and chloasmata are all due 
to excessive deposit of the natural pigment of the body in the rete 
musosum of the epidermis. Restoration of the normal color of the 
skin is usually proportioned to the extent and depth of the deposit, 
but the process is always very gradual. It can well be studied in the 
slow bleaching of the pigmentation of syphilitic cicatrices upon the 
lower extremities. In the dyschromias due to the introduction of 
coloring-matters foreign to the body or foreign to the skin the corium 
and the subcutaneous connective tissue are commonly stained. 

The origin of the pigment in the skin being still undetermined, 
pathologists are unsettled as to the question whether migratory pigment- 
conveying cells are responsible for the change of color in the skin or 
whether the pigment-granules themselves migrate. Kaposi, Jarisch, 
and a few others believe that pigment is formed in the rete. Unna 
believes there are two distinct kinds of pigment, not however fully 
differentiated, formed in the corium and carried through the lymphatic 
spaces to the rete. Ehrmann, 2 after much careful investigation, states 
that there are special pigment-cells, or " melanoblasts," which are formed 
in the embryo from the mesoderm. These cells perpetuate themselves, 
being thus independent of all other bodies, and are connected by long 
processes or threads of protoplasm, along which the pigment flows in a 
viscous state. The cells obtain their pigment from the haemoglobin of 
the blood. All pigment outside of these cells he considers hsematin- 

1 Internat. Atlas, 1892, vol. vi., 2 and 7. 

2 Bibliotheca Medica D. II., Part VI., 1896, W. G. Fisher & Co. (an illustrated mono- 
graph, giving results of his researches, and full bibliography) ; see also Ehrmann and 
Oppenheim, Archiv, 1903, lxv., p. 323 (report of further research, and complete bibli- 
ography). 



492 HYPERTROPHIES. 

detritus. In some of these cases there is no change in the walls of the 
blood-vessels and there are no signs of blood-extravasation. 

Diagnosis. — The diagnosis of cutaneous pigment-hypertrophies is 
readily effected by observing the persistence of the discoloration under 
pressure; the absence of all symptoms of hyperemia, inflammation, 
and secondary changes in the skin, as also by the characteristic shades 
of color presented to the eye. In tinea versicolor there is usually 
slight furfuraceous desquamation, and the existence of a vegetable par- 
asite is readily demonstrated by the microscope. The rare pigmentary 
syphilide is usually seen upon the neck and shoulders of infected women 
in the form of yellowish to brownish maculations, often arranged in an 
irregular network. The lesion is, indeed, one of the symptomatic 
chloasmata. 

Treatment. — In all the symptomatic pigment-anomalies the indi- 
cations for treatment are presented by the disease which begets the 
cutaneous disorder. 

The local treatment of both the idiopathic and symptomatic varieties 
of the affection demands the use of external applications which will 
hasten the physiological reproduction of the epidermis, substituting thus 
new and unpigmented for old and pigmented epithelia. This process 
must also be accomplished without the artificial production of such an 
hyperemia as will tend to add to the very coloration which it is 
attempted to relieve. The substances used for the slow accomplish- 
ment of this end are borax, sulphur, tincture of iodine, potassium and 
sodium hydroxides (including the soaps of these alkalies), and the mer- 
curials. None of these substances is more generally employed than 
corrosive sublimate, which constitutes the basis of most of the cosmetic 
lotions sold in the shops. 

The following formulae are given by White 1 for use in the evening. 
The preparation in each case should be left upon the affected surface 
during the night, and be removed by a soap-and-water washing in the 
morning. They are to be used for weeks in succession, but only after 
a cautious preliminary testing of the sensitiveness of the skin to their 
action. To avoid the possibility of error, the practitioner would do 
well to order a poison-label upon all vials containing the sublimate : 

R Hydrarg. am. chlor. 
Bismuth, magister., 



Amyl., ) 

Glycerin., J 

R Ammon. murat., 
Aq. Colognien., 
Aq. dest., 

R Hydrarg. bichlorid., 
Acid. mur. dil., 
Glycerin., 
Alcoholis, ) 
Aq. ros., j 
Aq. dest., 



aa 3ij; 


aa 8 


aa ^ss; 


aa 15 


3ss; 
Oss; 


2 

30 

240 


gr- vj ; 

fBJ; 


4 

30 


aa f Bij ; 


aa 60 


fSiv: 


120 



M. 



M. 



M. 



1 Loc. cit. 



aa 15 




30 


66 
M. 


aa 4 




8 
30 


M. 




4 


aa 2 




120 


M. 



CHLOASMA. 493 

The following formulae for ointments are given by Kaposi : 

01. rosmarin., gtts. x ; 

Ungent. simpl., §j ; 

B Acid, boric, ) -- -■ 

Cer. albse., j aa dJ ' 
Paraffin., 3ij ; 

01. amygd. dulc, 3 j ; 

Van Harlingen recommends : 

B Hydrarg. chlor. corros., gr. vss : 

Zinci sulphatis, I -- _ 

Plumbi subacetat., j aa dss; 

Aq. dest.. f giv ; 

Sig. Lotion, for external use, morning and evening. 

Other measures advised are : stimulation with alcohol, and applica- 
tion, for several hours after, of a plaster of ammoniated mercury; 2 
parts of magnesium carbonate and zinc oxide, 4 parts of pure kaolin 
and glycerin, and 10 of vaselin; chloroform, 100 parts, chrysarobin, 
15 parts (Leloir); hydrogen peroxide; diluted acetic, carbolic, muriatic, 
and nitric acids; 1 to 2 parts of salicylic acid, in paste or powder, to 
20 parts of base; and solutions of mercuric chloride in collodion, 1 part 
to 30, employed with great caution. 

The rapid removal of pigmented patches is accomplished, in Vienna, 
by covering the part with strips of linen dipped in an aqueous or an 
alcoholic solution of corrosive sublimate of the strength of 4 grains 
(0.26) to the ounce (30.), with which solution the dressing is also occa- 
sionally moistened. Vesiculation is usually accomplished in about four 
hours, when the serum is evacuated by puncture, and the detached epi- 
dermis is covered with any inert dusting-powder. The resulting crusts 
fall in about eight days. The procedure is attended with danger of 
producing in the end the precise deformity Avhich it seeks to remedy, a 
danger explained above. 

Another method of removing tattoo-marks and pigmented nsevi, 
successfully employed by French dermatologists, consists in tattooing 
the region, previously rendered aseptic, with a solution of 30 parts of 
zmc chloride to 40 parts of water. If properly done, the resulting 
inflammation is slight, and after a few days there forms a superficial 
crust which remains about a week and then falls, leaving a slight scar 
which becomes almost imperceptible. This method succeeds in a few 
cases, but requires skill and care in its application in order to obtain 
good results and to avoid suppuration and deep cicatrization. 

The internal administration of potassium iodide, recommended for 
the removal of argyria, has often failed. 

Prognosis. — The prognosis is in all cases uncertain. There is 
strong reason to believe that the local treatment of these dyschromias 
is, in the long run, ineffective. Those methods which effectually and 
brilliantly accomplish the desired end are almost invariably followed 



494 HYPERTROPHIES. 

by deeper pigmentation than that which it was attempted to remove ; 
those operating more slowly have, probably, a less speedy, but scarcely 
more disguised sequel. It is likely that local treatment of these pig- 
mented states will ere long be abandoned. The treatment intelligently 
directed to the cause of each discoloration is that which in the end 
proves most satisfactory. 

KERATOSIS. 1 

(Gr. Kepac, a horn.) 

The term Keratosis was first applied by Lebert to hypertrophic 
lesions of the epidermis. It has since been made to include changes 
in both the epidermis and the corium, and it is employed by some 
authors in a generic sense to embrace a number of both localized and 
general hypertrophies of these portions of the skin. 

KERATOSIS PILARIS. 

(Lichen Pilaris, Pityriasis Pilaris.) 

Symptoms. — This condition may be a mere temporary functional 
disturbance of the skin, awakening no subjective sensation, inappreci- 
able by the patient and apparent only to the careful observer, or it 
may constitute a disease. Its symptoms are the occurrence of pinhead- 
sized, pointed elevations of the skin-surface that may be described as 
papules, though, strictly speaking, they are not such, but are consti- 
tuted by an accumulation of horny epithelia and a small quantity of 
inspissated sebum about the lanugo-hairs of the extensor surfaces of 
the extremities and trunk. These aggregations of material are usually 
of a dirty-whitish or grayish hue, and are pierced by a lanugo-hair 
implanted in the follicle about which the abnormal condition exists. 
Occasionally, however, the hairs are of the finer and shorter kind, and 
are often coiled in or otherwise covered by the little heaps of epithelial 
debris. The skin of the individual thus affected is generally harsh, 
squamous, and dry to the touch ; being also, in the majority of cases, 
long unwashed. The color of the quasi-papules differs also with the 
complexion of the individual ; at times the papules have a distinctly 
reddish tinge, and they are often surmounted by a scale. 

Keratosis of this type can scarcely be described as a morbid state. 
Those who seek treatment for it are readily divided into two classes : 
first, comely young women desiring to exhibit bare arms in evening 
toilet ; second, young men suffering from the delusion that they are vic- 
tims of a " disease of the blood " or of syphilis. Viewed as a whole, 
the subjects of the best types of this so-called " disease " are men and 
women of exceeding vigor, with firm, well-developed muscles and 
shapely limbs. 

Keratosis pilaris is common in skins long uncleansed by ablution, 
and this condition can thus be produced artificially. In some individ- 

1 For bibliography, see Mibelli, Monatshefte, 1897, xxiv., pp. 345 and 415 ; and 
Janovsky, Mracek's Handbuch, vol. iii., p. 29. 



KERATOSIS. 495 

uals it persists for long periods of time, and awakens no concern. In 
others, especially in children, it speedily becomes the source of pruritus, 
and each lichenoid papule may then be transformed into an urticarial 
wheal, with distinct and sometimes very annoying pricking and ting- 
ling sensations, the trouble being at once relieved by a bath in w r arm 
water with soap. In still other individuals, especially in adults, an 
exaggerated form of the disease can be recognized, the skin presenting 
a roughness to the touch suggestive of the surface of a nutmeg-grater, 
and exhibiting numerous fine, conical, grayish, horn-tipped filaments, 
which several dermatologists are disposed to regard as a form of ich- 
thyosis. In the latter case there is doubtless a true hypertrophy of 
the epidermis. In the former case there is scarcely more than a me- 
chanical accumulation of effete organic material. There can be little 
doubt that the malady, simple though it be in character at the onset, 
may become the first stage of a series of chronic cutaneous disorders. 
Tilbury Fox has reported four cases, in which the disease was well 
marked, under the title of Cacotrophia Folliculortjm, this name 
being employed to designate its peculiarities as to wide distribution 
over the body, its implication of the deeper portion of the follicles, and 
its congenital history. In these cases the reddish tint of the lesions is 
shown distinctly. 

Brocq l describes a white variety, the uncolored circumpilary papules 
being scattered over the arms, forearms, legs, and thighs, usually on 
the outer faces of the extremities, and three inflammatory types : (a) a 
mild form, in which reddish papules are disseminated among those of 
the " white " class ; (6) a form of medium intensity, in which the 
papules are generally rosy-red in hue ; (c) an intense form, in which 
well-marked lesions occur over the surface of the chest, the lumbar and 
pubic regions, and the folds of the larger articulations. 

Keratosis pilaris on the face, as described by French writers, is 
characterized by exceedingly minute, usually conical, occasionally obtuse 
papules (each pierced by a fine hair) that develop over the brow, about 
the eyebrows, over the cheeks, and the inframaxillary region. 

Etiology. — Puberty and uncleanliness have been assigned as causes 
of the disorder ; both conditions may in some patients be indirectly 
effective. In certain individuals the condition seems to follow a pro- 
longed course of arsenic. The disease is seen frequently in persons 
having peculiarly thick, coarse, usually dark-colored skins, and also 
possessing marked muscular vigor and unusual development of most of 
the other bodily tissues. In brief, the disorder seems to be due often 
to marked inherited predisposition in persons of vigorous constitution. 
The varieties of keratosis pilaris seen in cachectic hospital-patients, and 
in persons who have aggravated the disease by inducing a medicamentous 
rash upon the person, belong to a different category. Patients in the 
two classes last named may be so perfectly relieved that there is no 
predisposition to a return of the disorder, a relief not always to be 
secured by the others. 

Pathology. — The papules are produced by a hyperkeratosis about 

1 Annales, 1890, s. iii., i., pp. 25, 97, and 222 (an extensive review of the subject, 
with bibliography). 



496 HYPERTROPHIES. 

the orfices of the pilosebaceous follicles. In some cases the result 
is an irritation which produces a mild degree of chronic inflammation 
of the periglandular tissue. Giovannini 1 found, in twenty-five cases, 
that inflammation was not constant, but in some instances was a marked 
feature. He found that the follicular orifices were much widened and 
deepened, and filled with a horny plug in which there were coiled often 
one or more fine hairs. The hyperkeratosis involved not only the 
follicle, but also the epidermis about it. There was more or less 
atrophy of the outer root-sheath of the sebaceous glands and of the 
erectores pilorum. In a few instances the entire follicle, including the 
hair-papilla, was destroyed. 

Diagnosis. — The disease should readily be recognized by the pecu- 
liarities of its seat, its course, and the nature of its symptoms. From 
ichthyosis it can be distinguished by the limitation of its lesions to 
the orifice of the hair-follicle ; from the transitory condition known as 
" goose-flesh " by its persistence after the surface of the skin is thor- 
oughly warmed ; from papular eczema and the other lichenoid erup- 
tions by the relatively insignificant character of the lesions, their evi- 
dent follicular origin, and either the entire absence, or mild chronic 
type, of inflammatory symptoms. 

The disease is to be carefully differentiated from pityriasis rubra 
pilaris, in which the characteristic disorder of the scalp, the appearance 
of plaques of disease covered with fine pityriasic scales (often upon the 
tip of the nose and chin), exhibiting a peculiarly dark, smirched appear- 
ance, the affection of the nails, the characteristic papulae on the dorsal 
surfaces of the first and second phalanges of the fingers, and the evident 
admixture of the disease with symptoms of seborrheic type, suffice to 
determine its nature. 

Though the lesions of keratosis pilaris bear little resemblance to 
the papular syphilodermata, many male patients for years swallow 
medicaments for relief of a supposed syphilis the sole " symptom " of 
which is a keratosis pilaris. The papular syphilodermata are not per- 
sistent year after year, are not throughout symmetrical, and are not 
limited largely to the outer faces of the limbs, especially of the thighs. 
They are preceded by a history of infection, and invariably are accom- 
panied by some other manifestations of the disease. They are not 
limited to the orifices of the hair-follicles, and are not capped by the 
peculiar horny scaling tip of the papule of keratosis pilaris. 

Crocker describes a Lichen Pilaris which he considers distinct 
from keratosis pilaris, as in the former the follicular elevations are 
more pronounced and resemble spines, there is usually evidence of 
inflammation, and the eruption tends to occur in patches instead of 
being diffuse. 

Treatment. — For the subjects of this disorder in its typical forms 
it is not sufficient merely to order a bath. The bathing should be 
conducted systematically for years at a time. 

As soon as it can well be tolerated the patient should be urged to 
bathe the entire surface of the body every morning by the use of the 

1 Lo Sperimentale, 1895, p. 662 (abstr. in Brit. Jour. Derm., 1896, viii., p. 151), 
and Archiv, 1902, lxiii., p. 163 (bibliography). 



KERATOSIS. 497 

sponge and cold fresh or salt water, following this with brisk fric- 
tion with a coarse towel or a flesh-brush. The habitual use of this 
cold bath continued daily for years, in persons who can tolerate it 
(and patients affected with keratosis pilaris are usually of this class), 
accomplishes results of the most satisfactory character, exerting, as 
it does, a profound influence on the nutrition and healthfulness of 
the skin. 

For immediate treatment of the most of these cases, however, the 
hot bath with soap is desirable. This bath may be repeated as often 
as required to remove the lesions, and be followed in the more urgent 
cases by inunction with lanolin-pomades, or the fats or oils. Salicylic 
acid, 1 to 10 per cent, in oils or ointments, is effective in removing 
temporarily the horny accumulations. In the congenital and severe 
types, such as those described by Fox, cod-liver oil internally should 
be ordered. 

KERATOSIS SENILIS. 

The skin of the aged may become harsh, dry, and unusually corni- 
fied either diffusely or in certain definite regions, such as the hands, 
feet, or extremities ; this may be regarded as the simplest form of 
keratosis senilis. The skin of the entire body or of the region affected 
is then dark in color, dry to the touch, occasionally covered with fine, 
rather adherent scales, representing merely attached and cornified cells 
of the horny layer of epidermis, and notably unprovided with the natu- 
ral unguent of the skin. 

In a more advanced grade the skin undergoes changes closely allied 
to epithelioma ; often, indeed, these both furnish the first symptoms of 
epithelioma and coexist with its gravest destructive effects. The skin, 
more commonly of the face, the hands, or the forearms, less often of 
the feet, the legs, and the genital regions of the aged, is covered with 
thin, horny, often greasy-looking, pinhead- to nail-sized and larger, 
dark-yellowish plates or scales, between which the integument that has 
undergone the atrophic changes in the senile skin is visible. Pig- 
mented puncta and macules may also appear scattered irregularly over 
the surface, with rough, dirty-yellowish to dark-brownish granular 
accumulations upon the skin of certain regions, such as the clefts beside 
the alse of the nose, the temples, etc. The appearance is suggestive 
in some cases of a seborrhcea sicca of the face. In many patients 
exhibiting these features a fully developed papillomatous, superficial, 
or deep epithelioma may be present. In other patients one or more 
varieties of the senile wart may be visible, as described in the chapter 
on Verruca. 

Viewing the subject of senile keratosis in the light of the knowledge 
had upon the subject to-day, it must be admitted that the boundary-lines 
between it and epithelioma are not well established. Unquestionably 
the exaggerated lesions of the former affection are frequently the first 
stages of the latter disease, and in the treatment of the skin of the 
aged, conducted on the general principles already set forth, the physi- 
cian should never lose sight of possibly serious consequences in one or 
more regions of the skin affected. 1 

1 Q'. Hartzell, Jour. Cutan. Dis., 1903, xxi., p. 393 (bibliography). 
32 



498 HYPERTROPHIES. 

Treatment. — In the mildest forms the use of simple bland oint- 
ments renders the skin less dry and therefore more comfortable. In 
the majority of instances, however, we have obtained the best results 
by the use of a simple ointment containing from 1 to 4 drachms 
(4.-16.) of sulphur to the ounce (30.) This may be rubbed gently 
into the skin once or twice a day. As a rule, the application should 
be preceded once a day by the use of hot water and a mild soap to re- 
move the fine scales or crusts that may be present. When the areas 
are thickened at all, the addition of from 1 to 5 per cent, of salicylic 
acid to the sulphur ointment is advisable. 1 In the more advanced and 
verrucous lesions the treatment is practically that recommended for 
senile warts. 

In many instances, though the use of ointments produces a marked 
amelioration of the condition, small areas of hyperkeratosis remain, 
unless removed by caustics, scraping, or other operative procedure. 

In a considerable number of cases, in several of which epithelioma- 
tous changes had begun, we have used the #-rays with excellent 
results, causing a complete disappearance of the hyperkeratosis. 



KERATOSIS FOLLICULARIS. 

(PSOEOSPEEMOSIS, DAEIEE's DISEASE, ICHTHYOSIS SEBACEA COENEA 

[E. Wilson], Keeatosis Vegetans [Crocker], Ichthyosis 

FOLLICULAEIS. Fl\, PSOEOSPEEMOSE FOLLICULAIEE VEOE- 
TANTE, ACNfi SEBACEE COENEE.) 

In 1889 Darier 2 and Thibault in France ; White in America; and 
later, Wickham, 3 Neisser, and others, called attention to a cutaneous 
disorder not previously distinguished from other maladies. Between 
twenty and thirty instances have been recorded. In reporting a new 
case Bowen 4 gives a summary of the clinical and pathological charac- 
teristics of the disease as described by other observers. Cases have 
since been reported by Hallopeau and Darier, 5 Bowen, 6 Little, 7 and 
others. 

In the few cases reported the eruption displayed was practically 
generalized, and was exhibited in greatest abundance over the limbs, the 
front of the chest, the inguinal and genital regions, the scalp, the face, 
and the loins. The first lesions were firm, pinhead-sized papules, scarcely 
different in color from that of the surrounding integument, which later 
assumed a deeper hue, and, whether flattened or hemispherical, these 
papules were soon covered with a grayish or brownish crust, greasy to 
the touch and apparently prolonged into depressions beneath, much as 
the crust of seborrhoea sicca of the face is sunk within the orifices of 
the sebaceous follicles. The papules, as they increased in size and age, 

1 D. W. Montgomery, Phila. Med. Jour., 1898, i., p. 211 ; and Stelwagon, Diseases 
of the Skin, p. 505, also recommend the use of sulphur and salicylic acid in these cases. 

2 Annales, 1889. , 

3 Contribution a 1' Etude des Psorospermoses cutanees, Paris, 1890. 

4 Jour. Cutan. Dis., 1896, xiv., p. 209 (review of literature). 

5 Annales, 1896, s. iii., vii., p. 737. 6 Ibid., 1898, s. in., ix., p. 6. 
7 Brit. Jour. Derm., 1901, xiii., pp. 51 and 98. 



KERATOSIS. 499 

became darker in hue until eventually they were a deep brown and red, 
or even purple. A few exhibited scratch-marks and were covered with 
hemorrhagic crusts. 

Over the scalp the symptoms are practically those of the crusting 
forms of seborrhcea, save that there is no tendency to loss of hair. 
Over the face the parts chiefly involved are the temples, the inside of 
the concha of the ears, and the folds about the nose and lips. Here, 
as over the parts of the trunk named above, form dark, even blackish, 
strata of dirty oil-crusts, spontaneously shed. Beneath each crust, as 
indicated above, there is usually a conical spur let into an infundibular 
depression, the latter representing the patulous orifice of a pilo-seba- 
ceous gland. Over the backs of the hand and fingers the papules and 
crusts are less numerous, but the papules are closely set together and 
tend to coalesce. In the palms and soles are numerous almost imper- 
ceptible lesions of the same type. As the disease advances to what 
has been described as a second stage the papules coalesce, forming 
small tumors and papillomatous growths, which involve not only the 
follicles, but also the interfollicular tissues. Many of the follicles 
become the sites of superficial ulcers, while the whole of the vegetating 
mass is bathed in a more or less abundant, fluid, muco-p undent secre- 
tion. The subjects of the malady often emit an offensive odor. 

The disease progresses gradually until large portions of the body 
are covered. Occasionally exacerbation with rapid spreading of the 
lesions occurs ; but, as a rule, the course of the affection is slow and 
the general health of the patient does not seem to suffer except sec- 
ondarily from the presence of ulcerating and suppurating lesions of 
the skin. 

Etiology. — Little is known definitely regarding the etiology of 
keratosis follicularis. In the majority of cases recorded it began in 
childhood, and in several instances in early infancy. Of twenty cases 
collected, thirteen were in males and seven in females. 

The theory first advanced by Darier, and later elaborated by Wick- 
ham and others, that this variety of keratosis, and probably also 
Paget's disease, some superficial forms of epithelioma, and molluscum 
" contagiosum," were due to the presence of psorosperms or coccidire, 
has been abandoned even by its propounders. As a result of further 
study by Bowen, Buzzi, Miethke, Boeck, Darier, and others, these 
bodies, which closely resemble certain psorosperms, have been demon- 
strated to be produced by cell-transformation. 

White's cases were in father and daughter, while Boeck had three 
cases in one family. Ehrmann l describes the case of a patient whose 
father he had seen in Janowsky's clinic with the same disorder. It is 
possible that contagion or heredity may have an influence in the pro- 
duction of the malady. 

Pathology. — The disease seems to be primarily a kyperkeratosis 
involving the sebaceous follicles and the hair-follicles. The process is 
confined for the most part to the neck of the follicle, but in the later 
stages it extends to the interfollicular tissues. The mouths of the pilo- 
sebaceous ducts are dilated into funnel-shaped openings and packed 
1 Abstr. in Brit. Jour. Derm., 1902, xiv., p. 41. 



500 HYPERTROPHIES. 

with masses of horny cells produced by the hyperkeratosis. Boeck 
and a few other observers believe, however, that the process is not 
essentially follicular, but that it may begin outside the ducts. » 

The rete is usually thickened and in the later stages of the disease 
the interpapillary processes are prolonged. Mitoses are numerous, 
and in the lower layers of the rete are found fissures or lacunae, the 
exact significance of which is not yet determined. In places the pres- 
sure of the horny masses may produce thinning and atrophy of the 
rete. About the borders of the lesions there is an abundant pigment- 
deposit in both the epidermis and in the corium. The only other 
change noted in the corium is a small amount of cellular infiltration. 
The glands of the skin are unaltered. 

The round bodies formerly supposed to be psorosperms are found in 
the deeper and middle layers of the rete, and at the base of the horny 
plug filling the follicle. According to Bowen, they are swollen cells 
containing a nucleus which stains deeply, and which is surrounded by 
a clear or hyaline ring of protoplasm, outside of which is a zone con- 
taining granules of keratohyalin, the whole being surrounded by a 
homogeneous, glistening membrane, which may possess a double 
contour. Various modifications of this type are found as a result of 
irregular keratinization of the cells. In the upper layers, in which 
the process of cornification is advancing, the keratohyalin gradually 
disappears ; but it may do so irregularly, and, losing its granular 
appearance, may give rise to appearances closely simulating nuclei and 
nucleoli. In the upper layers also the outer membrane may contract 
or disappear, leaving an empty space. At the bottom of the horny 
mass in the follicle the stratum granulosum is frequently absent, and 
there are seen irregular, shrunken, homogeneous cells with nuclei which 
stain but feebly. These cells are the " grains " of Darier, and BoAven 
believes they are cells which have become cornified without passing 
through the keratohyalin stage. 

Diagnosis. — The disease is to be differentiated from molluscum 
epitheliale, w r hich is never so generalized, and which always exhibits 
an enucleable mass containing the so-called " molluscous bodies." 
The papular forms of acne are eruptive elements which contain 
centrally a true corneous mass ; in keratosis follicularis there is a 
softish comedo-like central mass. The acne-forms, further, are not 
generalized. The disease bears close resemblance to some forms of 
ichthyosis, but a careful study of the history, the character, and location 
of the lesions will usually make the diagnosis clear. 

Treatment. — So few cases of the disease have been observed that 
the treatment is still undetermined. While marked improvement may 
be obtained, no complete recovery has been reported, and with a lapse 
in treatment the unfavorable condition of the patient quickly returns. 
The parts are to be w^ell cleansed by shampooings, and then dusted 
with borated, salicylated, and absorbent powders. The French, acting 
upon the parasitic theory of the nature of the affection, vigorously 
employ parasiticides, salves containing salicylic acid, sulphur, ichthyol, 
resorcin, pyrogallol, or iodoform, and even resort to cauterizations with 
zinc chloride. 



PLATE IX. 
















Keratosis Punctata in a Man who had been taking 
Arsenic for a long-standing Psoriasis. 






KERATODERMIA PALMARIS ET PLANTARIS. 501 



KERATODERMIA PALMARIS ET PLANTARIS. 1 

(Symmetrical Keratodermia of the Extremities, Congenital 
Keratoma of the Palms and Soles, Ichthyosis Palmaris 
et plantaris.) 

A symmetrical and well-marked thickening of the palmar and 
plantar epidermis occurs as a result of several effective causes to which 
special attention has been directed, in France by Besnier and Doyon ; 
in Germany by Unna ; and in the United States by one of the authors l 
of this treatise in a communication, in 1887, to the American Dermato- 
logical Association. 

Symptoms. — Four varieties have been identified : 

In the first variety there is symmetrical thickening of the palms 
and soles, strictly congenital, in cases hereditary, and accompanied or 
not by naevi situated upon other regions of the body. The epidermis 
of the involved areas is greatly thickened and a delicate erythematous 
halo extends beyond the border of the keratosis. The latter condition 
occasionally sweeps beyond the palmar and plantar regions to the dorsum 
of the affected fingers, toes, hands, or feet. The nails, the teeth, and 
the hair are not involved. 

The second group includes the more common variety of symmetrical 
keratodermia of the extremities, erythematous in type and possibly 
associated with a central neurosis. Here the epidermal thickening is 
exaggerated over the points of special pressure, though occurring inde- 
pendently of such agency, a fact well illustrated in a case in which the 
thickening at times developed while the patient was for months 
reclining in a hospital-bed. The disorder is worse in winter. There 
are the usual hyperaemic zone at the border-line of the keratosis, and a 
great distinctness of definition of the latter with perfectly sound skin 
between the islets of epidermis sclerosed at the points of pressure. 
There are usually a coincident hyperidrosis, and dislocation of and 
structural change in the nails. The keratinized sole or palm sheds its 
horny envelope either as a result of treatment or spontaneously ; and 
even in the most pronounced cases the disorder may disappear. 

In a third form there are foci in which the keratosis is declared in 
multiple isolated points over the palmar and plantar regions, always 
independently of pressure and contact, due to a central trophoneurosis. 
The remote cause in some cases is the long-continued ingestion of 
arsenic. In a subvariety the orifices of the sweat-pores are distended 
with corneous plugs, resembling comedones, with concentric lamellations. 

A fourth variety is a partial, entirely curable, and accidental kerato- 
dermia of the extremities that is not to be confounded with the callos- 
ities described in another section. This form occurs at any age under 
the influence of pressure to which the limbs are unaccustomed. 

. 1 For fuller discussion of the subject and bibliography, see Trans. Third Internat, 
Dermatol. Cong., London, 1896 ; and Dubreuilh, La Pratique Dermatologique, ii., p. 
927. 

2 " Observations on Three Cases of Symmetrical Hand aud Foot Disease," Med. 
News, 1887, li., p. 416 (3 cases, with bibliography). 



502 HYPERTROPHIES. 

Etiology. — The causes of the condition are not known. In many 
instances it is congenital and hereditary. Vomer 1 reports the disease 
as occurring in four generations, sixteen out of forty members of the 
family being aifected. Other instances in which the disease occurred 
through four generations are reported by Brayton, Decroo, and Pasini. 2 

The disease sometimes is acquired. Commonly it is preceded by or 
associated with hyperidrosis of the palms and soles. In many instances 
a neurotic origin is probable. Cases associated with psoriasis and 
other disorders of the skin for which arsenic commonly is given, often 
are due to the prolonged use of this drug. 

Pathology. — Vomer states that all the layers of the skin involved 
are thickened uniformly, and that cornification is normal in type but 
excessive. He found no evidence of inflammation. Pasini reports 
very great increase in the number of sebaceous glands. Other ob- 
servers describe marked elongation of the interpapillary processes with 
dilatation of the blood-vessels and the formation of irregular horny 
masses over the papillae. 

The Diagnosis of all forms of keratosis of the palms and soles is 
to be made from eczema, chiefly by reason of the absence of well- 
marked inflammatory symptoms, of vesicles, and of eczematous patches 
in other regions of the body. Palmar and plantar syphilides are to be 
distinguished with great caution. These last may be asymmetrical, 
especially if of " late " type ; may exist where there is often a history 
of infection or signs of lues ; and may often ulcerate. They have also 
well-defined circinate borders ; and the lesions are more often multiple 
and isolated. 

Treatment^ — Internal treatment is by the methods employed in 
psoriasiform affections. Brocq advises the internal administration of 
sodium arseniate in large doses ; but in this connection it should be 
remembered that cases are reported in which keratosis of the palms 
and soles has apparently been produced by a long course of arsenic. 
The local treatment is by prolonged maceration of the parts, followed 
by shampooings with green soap in substance or tincture, followed by 
salicylated pastes, plasters, or solutions of salicylic acid in collodion. 
Mercurial plasters and mercuric oleates may also be used with advantage. 
Potassium hydroxide in 1 to 20 per cent, strength has been applied as 
a lotion to stimulate the surface. Other formulae recommended are 
salicylic acid and calomel, 1 part of each to 20 parts of glycerole of 
starch ; and 1 part each of resorcin, tartaric acid, and salicylic acid, to 
20 or 30 parts of the salve-basis. 

In 3 cases we have obtained very marked improvement with a few 
applications of the «-rays. In one congenital case, that of a girl, five 
years of age, a keratosis involving the entire surface of both palms and 
soles, and so severe as to prevent extension of the fingers and to inter- 
fere with walking, disappeared almost entirely after 16 treatments 
during a period of six months. Eighteen months later the keratosis 
had not returned. 

Prognosis. — In the inherited and congenital cases complete removal 

1 Archiv, 1901, lvi., p. 3 (bibliography). 

2 Giorn. ital., 1902, xxxvii., p. 318 (bibliography). 



PLATE X. 




Palmar Keratosis, due to Arsenic. 



ANGIOKERATOMA. 503 

of the disorder is accomplished rarely, but by continued treatment the 
skin can be kept soft and the patient more comfortable. It must not 
be forgotten that hyperkeratosis of the palms and soles, or of other 
parts of the body, may terminate in epithelioma. 1 



telangiectasique [Dubreuilh] 



ANGIOKERATOMA. 

Icott Fox", 

•ocq], Verrite 



(Keratoangioma, Lymphangiectasis [Colcott Fox]. Fr., Angio 
keratome, Telangiectasis verruqueuse [Brc 



Angiokeratoma is a disorder characterized by the appearance of 
pin-head-sized and larger vascular dilatations, upon which are de- 
veloped later wart-like elevations. The disease occurs usually on the ex- 
tremities of individuals subject to chilblains. This affection was de- 
scribed first in 1889 by Mibelli f later, cases of a similar character though 
differing in many details have been reported by Thibierge, Crocker, 
Zeisler, Pringle, 3 Joseph, Fordyce, 4 Wisniewski, 5 and others. The cases 
are rare and they apparently occur with wide divergence of type. 

Symptoms. — The lesions may be first recognized upon the hands, 
where they resemble ordinary perniones, and are seated on the dorsal 
aspect of the fingers, especially of individuals who are much exposed 
to low temperatures or who handle cold substances in the trades, as, 
for example, those who dress cold beef in winter. Both the palms and 
the soles may be invaded. We have had under observation a typical 
case in which the lesions existed exclusively on the scrotum. Other 
instances of angiokeratoma of the scrotum are on record by Fordyce 
and others. Here, as over other regions of the body involved, the 
lesions may be commingled pinhead-sized and larger, translucent, 
horny-capped, roundish warts, tumors, or nodules, dull purplish in 
color, leaden-hued, or even chocolate-tinted, interspersed with flat 
macules (split-pea-sized for the most part, having a dark central 
punctum), which are at first removable by pressure and which event- 
ually persist. These lesions are often mere cutaneous varices. The 
globoid nodules may be smooth and horny at the surface or be rough- 
ened and prickly ; they are never scaly. At times the varicosities of 
vessels are commingled with both spots and nodules, transitional forms 
occurring in some cases. The arrangement of the lesions is in general 
irregular and asymmetrical, though there may be grouping. 

Etiology. — The patients are commonly young, but a few cases have 
been reported in middle-aged subjects. There is usually a history of 
exposure of the affected parts to cold weather or to cold substances, as 
described above. Some of the sufferers from the disorder seem to have 
been subject to chilblains. 

1 Cf. Hartzell, Jour. Cutan. Dis., xxi., p. 393 (bibliography). 

2 Giorn. ital., 1889, xxx, p. 527, and Monatshefte, 1895, xx, p. 309. 

3 Brit. Jour. Derm., 1891, iii., pp. 237, 282, and 309 (clinical and histological illus- 
trations, with review of published cases). 

4 Jour. Cutan. Dis., 1896, xiv., p. 81 (clinical and histological illustrations with 
bibliography). 

5 Archiv, 1899, xlv., p. 537 (bibliography and cuts showing histology). 



504 HYPERTROPHIES. 

Pathology. — The first change is a dilatation of the blood-vessels 
of the papillary layer to form punctiform capillary varices. The 
blood-stasis is followed by hyperkeratosis of the epidermal cells. 
Fordyce describes small spaces filled with blood in the papillary 
layer of the cutis, and also in the rete. He explains their occurrence 
in the rete by the supposition that the down-growth of epithelial cells 
surrounds and cuts off some of the terminal vascular loops in the 
papillae. There are, in addition, slight evidences of inflammation in 
the cutis beneath the lesions, and a marked thickening of the horny 
layer. 

The Prognosis is favorable, as the lesions may be made to disappear 
under proper treatment. 

Treatment is by stimulating lotions and liniments, as in pernio, 
and, when required, by electrolytic destruction of the vascular warts. 

KERATOSIS FOLLICULARIS CONTAGIOSA. 

(Acne sebacee coknee.) 

H. G. Brooke 1 described under this title a rare and apparently contagi- 
ous disorder occurring in children and occasionally in adults. Blackish 
macules were symmetrically developed into deeply pigmented papules 
over the neck, the shoulders, and the extensor faces of the arms. 
From these papules protruded blackish specks, which later resembled 
comedo-plugs and eventually developed as spike-like filaments. The 
skin, however, was dry, never greasy, of a dirty shade of color ; and the 
thorny excrescences were attached firmly to the tissue beneath. We have 
had under observation two young women who exhibited precisely the 
same features on the extensor surfaces of the arms, forearms, thighs, and 
legs. Unna divides the pathological symptoms into those due to reten- 
tion and those due to the formation of horny plugs at the sites of the 
follicles. The lesions are distinguishable from those of acne and comedo 
by the absence of sebaceous cells and by their collar of horny lamellae 
at the base. The spokes are produced by the energy of the hyperkera- 
tosic process, which pushes the horny plug outside of and beyond the 
follicle, its upper segment only being concerned in the process. The 
disease is essentially a hyperplasia of the epithelial cells, the first evi- 
dence of the operation of the external cause being apparent in the 
stratum granulosum, the chief result being declared in the common 
excretory duct of the pilo-sebaceous conduit. The disease was readily 
relieved by applications of lard saponified with potassium hydroxide. 

HYPERKERATOSIS STRIATA ET FOLLICULARIS. 

H. v. Hebra 2 reports under this title the case of a young woman 
with isolated epidermal elevations, having a reddish margin, of both 
superciliary arches, over the bridge of the nose, the upper lip, the 
throat, shoulders, and arms. The lesions were flat or elevated, iso- 
lated or confluent nodules, constituted of heaped-up epidermis, which 
could be removed without disturbing the papillary layer of the-corium. 
1 Internat. Atlas, 1892, xxii. 2 Ibid, 1891, v. 



POROKERATOSIS. 505 

Many were bean-sized, grayish-green elevations, conspicuous over the 
elbows, with underspreading epidermic cones buried in corresponding 
depressions beneath, which often bled freely when the cuticular mass 
was removed. Contrasting with these lesions were striated elevations 
of epidermis extending either at an angle or along the longitudinal 
axis of the limb. The disorder was relieved by warm-water and soap 
baths, followed by resorcin- vapor and salicylated plaster. 

PARAKERATOSIS SCUTULARIS. 

This name has been given by Unna l to a rare condition occurring 
in a vigorous man (first on the scalp), in which thick, somewhat greasy 
crusts enveloped bundles of hairs, the separate filaments having yel- 
lowish and horny cuffs that were fused with the crust. Whitish scales 
and horny cylinders with a perpendicular projection were visible over 
several portions of the face. Upon parts of the trunk were brownish 
spots, coin- to palm-sized, exhibiting horny cones which projected from 
the follicular orifices. The cones were covered with horizontally 
placed scales. Dark-reddish, moist, and shining surfaces were ex- 
posed on their removal. Closely examined, the horny cones after re- 
moval displayed several hairs which projected, one above another, 
from each cone, having been extruded from their follicles at different 
times. The author believes the disease to be allied to Devergie's 
pityriasis pilaris. 

POROKERATOSIS (Mibelli). 

(Hyperkeratosis Excextrica [Respighi], Keratodermia Excex- 
trica, Hyperkeratose figuree cextrifuge atrophiaxte 

[Respighi]). 

Tins rare form of hyperkeratosis, described by Mibelli, 2 Respighi, 3 
Hutchins, Wende, 4 Gilchrist, 5 and others, begins as a minute, elevated, 
wart-like^ papule which gradually enlarges peripherally to form a small 
plaque with a depressed centre and a characteristic, narrow, slightly ele- 
vated border, in the form of a " dike " or " raised seam/' along the* crest 
of which is a depressed black line or series of black dots. This crest 
may be continuous or be broken at intervals, or may be surmounted here 
and there by small conical elevations. This peculiar ridge inclosing a 
depressed centre can be made out in lesions that have attained a diam- 
eter of two millimetres or more. Many of the lesions do not reach a 
size greater than one centimetre in diameter, but some become much 
larger and may cover the greater portion of an extremity. The smaller 
plaques are circular, but the larger ones may have an irregular and 
sinuous outline. 

1 Internat. Atlas, 1890, i. 

2 Ibid., 1893, ix. ; Monatshefte, 1897, p. 345, etc. 

3 Giorn. ital., 1893, p. 356, and 1895, p. 69. 

* Jour. Cutan. Dis., 1898, xvi., p. 505 (clinical illustration, cut of histology, and 
bibliography). 

< 5 Johns Hopkins Hosp. Bull, 1897, p. 107, and Jour. Cutan. Dis., 1899, xvii.,p. 119 
(with clinical and histological illustrations and bibliography). 



506 HYPERTROPHIES. 

Within the border the surface in small lesions is depressed but 
callous, while in the larger areas it usually is thinned and atrophic, 
but may be of normal thickness, with sometimes a few small round 
horny elevations superimposed. Absence of hair and of perspiration 
is noted in some of the areas, while in others both are present. There 
are no evidences of inflammation, and as a rule no subjective sensa- 
tions. Some of the lesions may fail to attain typical development and 
exhibit a border but slightly elevated in which the furrow is the most 
conspicuous feature ; or they may appear as flat horny or scaly disks. 

The disease began in most instances between the second and eighth 
year of life, but in one of Respighi's cases it first appeared at the age 
of twenty-eight years. The lesions develop slowly, and may be limited 
for years to one region. The disks may be single, but usually are mul- 
tiple and may be very numerous. They occur in any region of the 
body, including the mucous surfaces. We have seen the disease in 
typical development on the glans penis, and Mibelli l records a case in 
which the lesions were limited to the mouth and glans penis. 

The causes of the disease are not known. Bacteriological investi- 
gations have given negative results. Gilchrist's eleven cases occurred 
in four generations of one family. Two other families are reported 
in which there were two or more cases of the disease. 

Pathologically the disease is a hyperkeratosis beginning in the 
deeper parts of the horny layer or in the upper portion of the rete, 
and involving chiefly the sweat-ducts, but also the hair-follicles and 
sebaceous glands. No inflammatory changes are found. 

Treatment of the smaller lesions with the electrolytic needle has 
been successful. Those which are larger may be excised. Recurrence 
after curetting was reported in one of Gilchrist's cases. 

, MOLLUSCUM EPITHELIALE. 2 

(Lat. molluscus, soft.) 

(Molluscum Verrucostjm, Molltjscum Sebaceum, Epithelioma 
Contagiosum, Molluscum Contagiosum (Bateman), Acn6 
VAFviOLiFORME (Bazin).) 

Molluscum epitheliale, a disease first recognized in 1817 by Bate- 
man, under the title Molluscum Contagiosum, is to be distinguished 
from another, known for a long time as molluscum fibrosum. The two 
disorders are distinct, and are no longer to be confounded by a simi- 
larity in name. 

Symptoms. — Typical epithelial mollusca are firm, roundish bodies, 
averaging in size the dimensions of a pea, and in color varying from 
a waxy whitish hue, nearly that of the integument, to the dark-red tint 
of injected masses. They are either imbedded in the skin or project 
from it in smooth, firm, semiglobular, sessile or pedunculated tubercles. 
Usually a dark-colored aperture can be detected at the apex or side of 

1 Archiv, 1899, xlvii., pp. 3 and 231. 

2 For a complete review of the subject with bibliography and additional research 
in the pathology and bacteriology of the disease, see White and Robey, Jour, of Med. 
Resell., 1902, vii., p. 255. 



MOLLUSCUM EPITHELIALE. 507 

the lesion, from which, on pressure, milky and curd-like, semifluid 
contents can be made to exude. Occasionally, inspissated or even horn- 
like masses project from these orifices, as though forced out by a vis-a- 
tergo. The disease is rare, and the lesions are usually single and iso- 
lated, though hundreds may appear upon the person of one individual. 

Fig. 50. 




Molluscum epitheliale. (After Allen.) 

They consist of semifluid collections derived from that portion of the 
rete which lines the sebaceous glands or penetrates between the papillae 
of the derma; or they are actual transformations of the glands into 
cornified amorphous deposits, surrounded by thickened parietes. They 
may be removed by surgical procedures ; or be shed spontaneously ; or 
inflame, and result in circumscribed abscess ; or terminate by ulcera- 
tion. More often they are insidious and slow of development, and may 
persist for years without producing annoyance or subjective sensation. 
They occur on the face, the side of the neck (Fig. 50), and the nucha; 
on the penis and scrotum of men, and the breasts and labia of women; 
on the trunk; on the flexor surfaces of the extremities, and the dorsal 
surfaces of the hands and feet. They are most common in children. 
In consequence of the depression of the centre of the little tumors 
(which Hutchinson has happily likened to small pearl buttons) they 
may suggest the lesions of variola, hence they were described by Bazin 
under the term Varioliform acne. This title, however, is by most 
writers employed to designate a totally different affection, a variety of 
acne vulgaris, to which a chapter is devoted in this work. 



508 



HYPER TR OPHIES. 



Hebra, Virchow, and Mcolaysen have reported mollusca as large 
as an orange or a small cocoanut. Microscopical examination of these 
gigantic lesions demonstrated their identity with the smaller tumors. 
Similar bodies of less size have been found interspersed among 
epitheiiomata. 

Etiology. — In England where the disease was first recognized, it 
is more frequent than on the continent of Europe. The contagiousness 
of molluscum is experimentally established, though the lesions are 
feeble in propagation by contact. Retzius, Vidal, Peterson, and Wig- 
glesworth succeeded in producing the disease by inoculation of the 
contents of molluscous tumors. The proofs of contagion apart from 
experimental inoculation rest chiefly upon the circumstance of lesions 
being simultaneously or successively observed on the breast of a mother 
and the face of her nursling, and upon the successive development 
of mollusca in several members of one family. An interesting relation 
would seem to subsist between mollusca and verrucse, or ordinary warts, 
which are supposed to be feebly contagious. 

Stelwagon l has accumulated and classified reports of cases and of 
inoculations which seem to leave little doubt as to the parasitic nature 
of the disease, though no definite organism has yet been demonstrated 
in, or cultivated from, the growths. Eczema, t sweating (Turkish baths), 
pruritus, and maceration of the skin predispose to the occurrence of 
mollusca ; but there are insufficient grounds for assuming that in adults 
they are associated with venereal disease. They are seen not rarely in 
large numbers upon the scrotum of youths who have never exercised 
the sexual function. 

Pathology. — Sections through the centre of a lesion of molluscum 
epitheliale show that it is formed by a number of diverging flask- 
shaped lobules, the small end of each lobule 
opening into a common central cavity. The 
lobules are separated from each other by a 
thin fibrous partition, which may occasion- 
ally be demonstrated to be the remains of a 
papilla. The entire mass or group of lobules 
is surrounded, except at the surface-open- 
ing, by a fibrous capsule, thus giving the 
entire structure an appearance very similar 
to that of a sebaceous gland. The belief, 
formerly held, that the process originated in 
the sebaceous glands, is erroneous. Minute 
examination fails to find any trace of a seba- 
ceous gland in these formations. The process begins as a proliferation 
of epithelial cells in the lower layers of the rete. The growth is con- 
fined to the rete, from which the flask-shaped processes are pushed out, 
causing a flattening and more or less complete disappearance of the 
underlying papillae. 

Each lobule is lined with a layer of palisade-cells continuous with 
the same layer in the healthy rete adjoining the growth, and is filled 
with round and cuboidal nucleated epithelium undergoing peculiar 
1 Jour. Cutan. Dis., 1895, xiii., p. 50. 



Fig. 51. 




Molluscous corpuscles. 
(After Kaposi.) 



MOLLVSCUM EPITHELIALE. 509 

changes. The first two or three rows of cells are usually normal, 
but above them the changes become gradually more marked. The 
exact nature, sequence, and signification of these changes are in 
dispute, but it would seem to be fairly well established that the outer 
part of the cell shows early in the process abundant granules of kerato- 
hyalin, and soon undergoes a cornification forming a clear ring or 
" capsule " for the cell. Within, the changes have been considered 
similar to those seen in amyloid or colloid degeneration, but C. J. 
White l found that in over nine hundred sections the staining reaction 
of the molluscum bodies was identical with that of normal keratin. 
Authors describe a granular condition surrounding the nucleus, which 
is usually at one end of the cell, while the remainder of the cell- 
protoplasm shows vacuoles or groups of small, irregularly shaped 
hyaline bodies, uniting to form an oval mass which gradually en- 
croaches upon and distends the cell. This oval homogeneous cor- 
puscle surrounded by a horny capsule forms the so-called " molluscum 
body." These bodies accumulate at the mouths of the lobules and in 
the small common cavity in which the lobules all open, and may be 
pressed out upon the surface of the skin in a yellowish or whitish 
semifluid or waxy mass. 

The more minute changes in the cells and the methods of recogniz- 
ing them are given in detail by Unna and others. The theory that the 
disease is caused by psorosperms has been abandoned. 

Diagnosis. — Mollusca resemble the lesions of variola more than any 
other cutaneous phenomena. They are, however, readily distinguished 
from the latter by their chronicity, their semifluid contents, the absence 
of febrile symptoms, and the career of variolous pustules. From 
warts they are also differentiated by their contents, hemispherical shape, 
and the dark punctum almost invariably present on one part or another 
of the lesion. 

Molluscum epitheliale in no way suggests molluscum fibrosum, with 
which it has been confounded only in consequence of the similarity in 
name. The tumors of molluscum fibrosum are solid new r -growths, 
usually occurring in great numbers upon the trunk of individuals of 
adult years. They may attain enormous dimensions, the masses 
reaching several pounds in w r eight ; and though in cases they degen- 
erate by ulceration, they never enclose the curdy contents of molluscum 
epitheliale. 

Papillary warts are to be distinguished from mollusca, though with- 
out question lesions are occasionally seen of a type intermediate between 
the two forms. Warts are to be recognized by their general papilli- 
form character, and by their evident relation to the papillary layer of 
the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have discov- 
ered mollusca upon the genitals, and who suppose these lesions to be 
of venereal origin. An error in this respect can scarcely be committed 
by the expert. Neither the solid papule of the initial lesion of syphilis 
when observed on the skin of the penis, nor the pustule and resulting 
ulcer of the chancroid, even exhibit the waxy look of genital mollusca 

1 Loc. cit. 



510 HYPERTROPHIES. 

with their depressed puncta. In such cases the inguinal glands should 
always be examined carefully, remembering, however, that a forcibly 
squeezed and cauterized molluscum may be accompanied by sym- 
pathetic adenopathy. 

Treatment. — When the tumors are few in number they may be 
removed by pressing the contents out through the central orifice. In 
some instances this slight operation is facilitated and rendered less 
painful by first making a linear incision over the growth. In children 
and others sensitive to the pain, the surface may be rendered anaes- 
thetic by the use of ice or ethyl-chloride spray. Bleeding is arrested 
easily with a pledget of lint. Occasionally after removal of the con- 
tents the point of a crayon of silver nitrate may be introduced either 
to check hemorrhage or insure destruction of the cyst, or carbolic acid 
may be introduced on the end of a pointed stick. 

When the lesions are numerous, they may be made to exfoliate and 
disappear by the local application of green soap. Stelwagon recom- 
mends in such cases the use of an ointment containing 20-40 grains 
(1.3-2.6) of white precipitate or of sulphur to the ounce (30.), the 
ointment being rubbed vigorously into the affected parts once or twice 
a day. 

Prognosis. — The disease can always be terminated by removal of 
the tumors, the process to be repeated in case of recurrence. 

CALLOSITAS. 

(Lat. callus, hard flesh.) 

(Callosity, Keratoma, Tyloma, Tylosis. Ger., Verhartung.) 

Callosities are acquired superficial, circumscribed, dirty-white, yel- 
lowish-white or darker, flattened, thickened, and horny patches of epi- 
dermis, dense in structure, usually insensitive, and occurring for the 
most part in regions of pressure and friction on the hands and feet. 

Symptoms. — Callosities vary in size from that of a finger-nail to 
that of a section of a hen's egg, being at times larger ; they occur chiefly 
upon parts of the integument subjected to long-continued intermittent 
pressure, as the hands and feet ; also upon parts stretched over osseous 
prominences, as those over the ischia. Section of a single plaque shows 
it to be largest at the centre and least at the periphery. They may be 
complicated by hypersemia, fissure, acute inflammation, or erysipelas ; 
and readily serve as foci of cutaneous disease (eczema, psoriasis, etc.). 
They are commonly encountered among mechanics, carpenters, shoe- 
makers, etc. ; among persons wearing no coverings for the feet or ill- 
fitting shoes (heel, or ball of foot, or big toes), stockings, or surgical 
apparatus; among workers in metals, acids, or heated substances; and 
among musicians (harpers, banjo-players, etc.). They are produced by 
such external causes as pressure, friction, chemical agents, and heat. 
They can readily be distinguished from eczematous, psoriasic, and ich- 
thyotic patches, being always limited to the sites of external contact. 

Callosities are so characteristic of the several professions and trades 
that by their locality alone they point in many cases to the occupation 



CLAVUS. 511 

of the individual who exhibits them. Often they are, in these eases, 
essential to the prosecution of such work ; and their removal would 
only expose a tender epidermis to the operation of injurious pressure 
or friction. 

The pathological features of callosities are: marked hypertrophy 
and compaction of the stratum corneum and thickening of the stratum 
granulosum, the rete mucosum on the contrary being thinned by the 
pressure. The papillae are often flattened from the same cause. The 
corium may exhibit signs of inflammation when the callosity has been 
converted into a source of irritation. 

Callosities require treatment only when they are sources of pain or 
of discomfort. They may be removed — surgically, by the knife ; chem- 
ically, by the destructive action of acids or alkalies ; rationally, by dis- 
use of the part to an extent sufficient to interfere with the operation 
of the cause. When painful they may be poulticed. A nightly soak- 
ing of the callus with warm oil, kept in contact with the thickened 
epidermis during the hours of sleep by a compress of flannel saturated 
with the same substance, will in the end soften the induration. Other 
methods of treatment advised are : the continuous application of a 10 
to 25 per cent, salicylic plaster or mull (Stelwagon) : the salicylated 
collodion-paint recommended for corns ; and the scraping away of the 
outer layers of the epidermis with a dull knife after soaking in solution 
of lactic acid, borax, or weak potassium hydroxide solution, protecting 
the part afterward with zinc-oxide plaster. 

Callositas of the Hands, with Unusual Complications 
(reported by Morison, 1 of Baltimore), is illustrated by the case of a 
negro who was a stoker. In this instance the combined effects of heat 
and friction resulted in ulcerations beneath the callosities that event- 
ually produced necrosis and loss of some of the phalanges. This 
patient recovered as soon as the hands were properly protected, a fact 
that seems to justify the assignment of this and similar cases to a class 
apart from those which follow. 

CLAVUS. 

(Lat. clavus, a nail.) 

(Corn. Fr., Cor, CEil de Perdrix ; Ger., Huhnerauge, 
Leichdorn.) 

Corns are circumscribed, conically shaped hypertrophies of the 
horny layer of the epidermis, presenting inferiorly a prolongation, 
which, being pressed from without inward upon the sensitive papillae 
of the corium, excites pain in various degrees. 

Symptoms. — Corns vary in size from that of a pea to that of a large 

chestnut, and commonly are described as "hard " or " soft/' The former 

are dense and callous, occurring upon those prominent parts of the foot 

on which the boot, shoe, or gaiter exercises its greatest pressure. Soft 

1 Jour. Cutan. Dis., Jan., 1886. 



512 HYPER TR OPHIES. 

corns develop upon the lateral face of a toe in apposition with another, 
the lesion originating from pressure through the medium of the neigh- 
boring toes. It is softer in consequence of exposure to heat and moist- 
ure. Corns are often weather-sensitive, being unusually painful 
before, during, or after the occurrence of storms, and should not be 
confounded with gouty or rheumatic deposits below the skin. They 
are seen occasionally upon the palms of the hands and, when occurring 
upon the soles of the feet, are often the sources of severe distress. 

The modern methods employed by the manicure and the chiropodist, 
often ignorant of the measures requisite to insure asepsis both in their 
instruments and hands, are often responsible for a series of disorders 
which are encountered not rarely by practitioners in the larger towns 
of all countries. Suppuration beneath the conical plug forming the 
corn is not rare, and not only may eczema, erysipelas, and other in- 
flammatory affections be excited to activity by their procedures, but 
even a grave lymphangitis spreading the length of the entire extremity 
may result. 

Histology. — Corns are composed of superimposed, and often con- 
centrically arranged, layers of epithelium, between which are found at 
times minute hemorrhagic extravasations. At the periphery of the 
corn the corium is unchanged, but at the point where its central cone is 
pressed into the deeper structures the papillae are either atrophied or 
absent. A corn at the periphery exhibits, according to Unna, a thicken- 
ing of the prickle- and granular layers. There is a central horny layer, 
the outermost stratum of which gives evidence of "welding." But the 
core itself, which is composed of compressed masses of the horny layer 
conically pointed below, exhibits a flattened ridge-net and papillary body. 
Often the sweat-pores are preserved, and may be traced running dilated 
and with many windings through the epithelium deeply into the core. 
The granular layer here disappears, and the general flattening is so 
great that the margin between the horny cells and the flattened prickle- 
layer is lost. 

Treatment. — Corns, when rationally treated by disuse of the feet, 
or by the adjustment of properly fitted coverings for the same, will 
usually fall spontaneously. They are always shed from the feet of the 
paralyzed. They may be softened by prolonged maceration in water, 
by poultices, or, best of all, by oil, as in the treatment of callosities. 
Erasion, dissection, and excision may be practised, if demanded by 
an exigency. Where the sufferer necessarily must continue the use of 
the foot, the simplest and best treatment is as follows : The part is 
macerated thoroughly for half an hour with water as hot as can be 
tolerated. Then the projecting callous portion of the corn is removed 
by gently cutting or scraping until, as nearly as may be, the surface 
is level with the plane of the adjacent skin. Then the part is dried, 
and the entire surface, both of the seat of the corn and the adjacent 
integument, is covered completely with many narrow, short, and nicely 
adjusted strips of rubber-plaster. Burgundy pitch melted and painted 
over the part may be applied as a substitute for the plaster. When 
the trifling operation and dressing are complete the patient should 
bear firm pressure over the corn without flinching, and walk with 



CORNU CUTANEUM. 513 

comfort. The plaster remains until it separates spontaneously, which 
is usually in the course of a few days. The corn is then macerated at 
night with an oil-poultice, as described above, and the dressing after- 
ward reapplied, usually the second time by the patient. Persistence 
in this course is followed by complete relief if the coverings of the 
feet be properly fitted. Caustics are usually unnecessary when there 
is no ulceration of the hard corn, and are in this situation frequent 
sources of great distress. They are chiefly valuable in the treatment 
of the soft variety, but they should always be applied with a skilled 
hand. 

For this purpose acetic acid or the silver nitrate crayon may be 
employed. The proprietary " corn-salves" sold in the shops commonly 
contain the ointment of mercuric nitrate, which also in reduced 
strength is a useful application to the soft variety of corn. The 
latter should be protected by the interposition of absorbent cotton 
or wool from contact with adjacent toes. 

As a rule, the ringed corn-plasters sold in the shops are inferior to 
the dressing with the rubber or salicylated plaster, made to cover the 
entire corn. 

Soft corns occasionally require pencillings with the silver-crayon 
after the outer horny layer is removed. Corns may also be removed 
by the salicylated collodion employed for warts (q. v.). 

CORNU CUTANEUM. 1 

(Lat. cornu, a horn.) 

(Cutaneous Horn, Cornu Humanum. Ft., Corne de la Peau ; 
Ger., Hauthorn, Hornauswuchs.) 

Cutaneous horns are rare corneous excrescences greatly varying in 
shape and size, often resembling the similar growths in the lower 
animals. 

Symptoms. — Cylindrical, conical, straight or twisted, angular and 
otherwise irregularly shaped and sized corneous eminences, commonly 
single or more rarely multiple, occasionally project from the scalp, 
forehead, nose, lips, ears, penis, or extremities. The sites of preference 
are in the following order, the scalp, forehead, temples, nose, lower ex- 
tremities, male genitals, and trunk. Horns are named from their 
resemblance to the similar appendages in horned cattle, but they 
widely differ from cattle-horns, which are always implanted upon 
osseous tissue. Human horns are formed of dense and massed columns 
of epithelia, often resting upon prolonged papillae. Occasionally, on 
section, they exhibit the concentric arrangement of the epithelia seen 
in corns, but, unlike the latter, have re-entrant basal depressions into 
which the papillae below penetrate. At times they are implanted in a 
dilated follicle, in which case the glandular elements participate in 
their formation. At times, also, they represent a corneous transforma- 
tion of the epithelia which constitute warts. They are seen in all 

1 For review of the subject, with bibliography, see Marcuse, Archiv, 1902, lx., 
p. 197 ; and Pasini, Giorn. ital., 1902, xxxvii., p. 475. 
33 



514 



HYPERTROPHIES. 



colors, but are often between a yellowish brown and a brownish black, 
with fissured or wrinkled or longitudinally grooved exterior, like rough 
bark (Fig. 52). They may be painless, or, like other keratoses, become 
the seat of inflammation in various grades. They may be short or 
several inches in length (Fig. 53). They may be shed spontaneously 
never to return, or may shortly reappear. They occasionally develop 
into epitheliomata. 

Brinton l has exhibited an Fig. 53. 

anteriorly curved horn one and 
seven-eighths inches long and 
three-eighths of an inch in cir- 
cumference, removed by him 
from the glans penis of an 
elderly patient. Fourteen cases 
are on record of a similar 
growth in this situation. In 
the horn growing from the 
lower lip of an elderly man 
exhibited in 1886, at our 
clinic, the growth was longi- 
tudinally furrowed, and also 
at somewhat regular intervals 
transversely seamed, present- 
ing thus the appearance of the 
joints of the sugar-cane. 



Fig. 52. 





Varieties of cutaneous horns. 

The Etiology is without question that of the senile wart for most 
cases ; though, as with epithelioma, horns occur in infancy. They have 
been recognized as starting from a sebaceous cyst. They develop, if at 
all, more often after the fortieth year of life, though occurring in infancy 
and with slightly greater frequency in women than in men. 

Pathology. — Pathologically these hypertrophies are developed first 
either within a closed atheromatous cyst or from remarkably elon- 
gated papillae of the corium. They are made up of cornified and 
hypertrophied epidermal cells. According to Unna, they are all papil- 
1 Jour. Cutan. Dis., 1887 ? vi., p. 272, 



VERRUCA. 515 

lary and medullated keratomata growing on a circumscribed warty 
base. The first stage of their development is characterized by a sim- 
ultaneous acanthosis and hyperkeratosis, dense epithelial taps reaching 
toward the corium. In the second stage of horn-formation the kera- 
tosis advances and the acanthosis diminishes. Sets of horny wedges 
sink downward into the epithelial taps and ridges, fill the spaces be- 
tween the papillae, and are capped above by a horny cupola. 

Lebert shows that horns develop into epitheliomata in about 12 
per cent, of cases. As horns are really metamorphoses of epidermal 
cells similar in many features to warts, it is not surprising that the two 
often undergo the change from benign to malignant epithelial growths. 
In a few cases horns have developed to an appreciable degree on epi- 
theliomata; but under the microscope this horny metamorphosis on a 
smaller scale may be recognized in a large number of epitheliomata sit- 
uated on the back of the hands of elderly men who have been farm- 
laborers, sewer-builders, or workers in contact with earth. 

Treatment. — Horns may be removed by extirpation after softening 
with alkaline dressings, after which the surface upon which they were 
implanted should be cauterized thoroughly to insure a failure of return. 

Prognosis. — In formulating a prognosis the possibility of an epi- 
theliomatous result should not be forgotten. 

VERRUCA. 

(Lat. verruca, an excrescence.) 

(Wart. Fr. } Yerrue ; Ger., Warze.) 

Warts are cutaneous excrescences ; congenital or developing after 
birth ; split-pea-sized to many larger dimensions ; sessile or peduncu- 
lated ; pointed or flat ; smooth, rugous, or having a cauliflower appear- 
ance, pigmented in various shades or of the natural color of the skin ; 
soft, dense, or corneous to the touch. They may develop slowly or 
rapidly, and may persist for years or disappear without apparent cause. 
They may be single, multiple, or exceedingly numerous ; and occur 
upon the hands, feet, face, scalp, neck, genitals, and other parts of the 
body. They are usually discrete, but may be confluent and form palm- 
sized and larger elevated plaques. Fox, of New York, has reported a 
case in which warts occurred in the lines tattooed on the skin of a 
young man. 

The several names given to the various forms of warts have chiefly 
a descriptive value. 

Yerruca Acuminata y (Condyloma Acuminatum ; Moist or 
Yenereal Wart, Fig-wart ; Ger., Spitzenwarze, Yenerische 
Warze, Feigwarze, Spitzencondylom) is a filiform, papilliform, 
or cock's-comb-like vegetation, developing both upon the mucous mem- 
branes and the cutaneous surface. They are single or multiple ; at 
times hundreds coexist upon the genitalia and neighboring regions. In 
size they vary from that of a pin's point to that of a hen's egg, and may 
be larger. They are usually moist and secreting, frequently being cov- 
1 For bibliography, see Joseph, Mracek's Handbuch, viii., p. 500. 



516 HYPERTROPHIES. 

ered with a puriform mucus of exceedingly nauseating odor. The 
secretion at times desiccates so as to cover the lesion with a thin crust. 
The warts are often the seat of a very considerable pruritus. Upon 
the genitals they are encountered upon the glans, around the frenum, 
and over the prepuce of men ; and in women about the clitoris, labia, 
ostium vaginae, and anus. They are usually of a bright-red color in 
these situations. When occurring upon the integument they are firmer, 
drier, and exhibit a tendency to luxuriant growth. In this form thev 
may be recognized about the axillary regions, the umbilicus, the inter- 
digital spaces of the feet, and even the face. They may cover the side 
of the chin. 

The summit of these warts may be tufted, acuminate, or flattish ; 
on the surface of the skin, unconnected with mucous membrane, they 
may have the color of the unaltered integument. They are often 
minute and numerous as well as multiple and large ; or they may be 
single throughout, though, as a rule, they multiply when untreated. 
Their largest maximum development is observed in negroes, in whose 
persons they may attain unusual proportions. There was lately exhib- 
ited at our clinic a male negro with a compound venereal wart of the 
penis that was of the size of an orange. 

These warts are almost always the result of exposure of the sexual 
parts to venereal secretions (blennorrhagic, syphilitic, leucorrhoeal, etc.), 
and, though observed in virgins, are decidedly rare in individuals of 
both sexes of that class. In pregnancy they often attain a large size 
and rapid development, but, as a rule, disappear when parturition is 
completed. They are contagious and furnish auto-inoculable secretions. 
Cocci and bacilli have been recognized in several varieties, thus explain- 
ing many otherwise obscure histories. 

Verruca Acquisita is a term used to designate lesions developed 
after birth. 

Verruca Congenita. — Congenital warts are usually first noticed 
several months after birth. They may be single or be multiple, 
usually the latter, in which case they are arranged along the lines of 
distribution of the nervous trunks, the disposition of the lesions often 
suggesting the arrangement displayed in zoster of the trunk or other 
region. They are, as a rule, roundish, slightly pigmented, and scarcely 
larger than split pease. At times they acquire unusual dimensions. 
The neck and shoulders may be well covered with lesions of this class 
in asymmetrical groups, the largest wart having the size of the section 
of an egg. 1 

Verruca Digit at a is a term descriptive of the form of wart ex- 
hibiting finger-like prolongations separable from base to point. Often 
each separate filament is horn-capped. This type of lesion often occurs 
as a succedaneum in other affections (e.g., blastomycosis of the skin, 
syphilis cutanea capillitii, etc.). 

Verruca Filiformis. — This variety of wart differs somewhat from 
the others, not only pathologically, as is noted below, but also in its 
clinical features. These warts are pointed growths, soft, slender, thread- 
like, often pedunculated, usually covered with a smooth and apparently 

1 Cf. Naevus Pigmentosus, Nsevus Verrucosus, Nsrvus Unius Lateris, etc. 



PLATE XL 




Congenital Warts. 



VERRUCA. 517 

unaltered epidermis ; they occur upon the face, neck, eyelids, chest, 
and ears. Kaposi concludes that they are minute fibromata. 1 

Verruca Dorsi Manus et Pedis (Unna) is a naevus with 
lesions symmetrically grouped upon the dorsal surfaces of the meta- 
carpi of the thumb and index finger. The lesions are flat, round, or 
polygonal, two to six millimetres in diameter, externally presenting a 
punctate appearance, occurring in middle or later life, and exhibiting 
no tendency to spontaneous change. Pathologically they disclose a dis- 
tinctive thickening of the prickle-layer from the periphery to the 
centre. They lack many of the characteristic microscopical features of 
the ordinary seborrhoei'c wart. 

Verruca Glabra is distinguished by its smooth surface. 

Verruca Necrogenica is a tuberculous wart, occurring on the 
hands of persons who have been in contact with tubercle-bacilli, chiefly 
as a result of handling the bodies of the dead. For details, the chap- 
ter on Tuberculosis of the Skin should be consulted. 

Verruca Plana (Verruca Plana Juvenilis 2 ) is a not un- 
common variety of wart, flat, smooth, and but slightly elevated. The 
plane warts may be single, but are commonly multiple, and they 
usually vary in size from that of a pinhead to that of a small split-pea, 
but may be much larger. They often are grouped, and may have a 
polygonal outline, closely simulating the papules of lichen planus. In 
young people these plane warts are usually small, multiple, often 
grouped ; have the color of the normal skin or are slightly yellowish 
or whitish, occasionally bluish ; and are seen most frequently on the 
forehead, on other parts of the face, and on the backs of the hands. In 
older people this form of wart shows less tendency to grouping than in 
the young, often is pigmented, and may be associated with or form the 
beginning of superficial epithelial changes. 

Verruca Senilis vel Plana (Verruca Seborrheica, Kera- 
tosis Pigmentosa). — These warts are small pea- to coin-sized, and 
larger, smooth, softish growths developed upon the face, trunk, and 
extremities of persons of advanced years. They are flat, usually pig- 
mented, and have a granular aspect. They are readily separable by 
the finger-nail, and then are found to rest upon a reddish granular 
base. As the result of external injury (caustics, traumatism) they may 
become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the 
fingers and hands, as single, multiple, or exceedingly numerous, pin- 
head- to pea-sized, usually discolored, papilliform excrescences, dense 
or softish, rapidly or slowly developed. The top of each is commonly 
grayish, yellowish, or blackish in tint. Exceptionally these warts 
develop on the soles of the feet (where they are often mistaken for 
corns), the borders of the lips, the scalp, the axillae, and the groins. 
Upon the fingers an exceedingly annoying site is within or upon the 
nail-folds and beneath the free borders of the nails, situations often 
affected in several fingers of both hands, especially in young women. 

1 See Taylor's observations as epitomized in the chapter on Fibroma. 

2 For bibliography, see Joseph, Mracek's Handbuch, vol. iii., p. 518. 



518 HYPERTROPHIES. 

Etiology. — Most warts are nests of micro-organisms of different 
varieties. The precise cause, however, is unknown j but in early child- 
hood, a period in which warts frequently are encountered, it is reason- 
able to conclude that they result from external contacts. It is when 
the child begins to handle everything within reach that they usually 
first appear, and then about the hands. They are probably in a feeble 
measure both auto-inoculable and infectious. Fox, Allen, and Stel- 
wagon have recognized coexistence in one subject of both warts and 
moll u sea. Jadassohn inserted fragments of ordinary warts from four 
patients in superficial incisions of the epidermis in six different adults. 
Out of seventy-four inoculations, thirty-three were followed in from 
two to six months by the development of warty lesions. 1 Acuminate 
or condylomatous warts chiefly occur in parts moistened with a blenor- 
rhagic secretion, but unquestionably they may originate from contact 
with leucorrhoeal or pathological, non-venereal discharges from the 
female genitals. Senile warts are more probably due to obscure 
changes in the nutrition of the integument. The etiological import- 
ance of the cocci and bacilli wdiich many of them furnish cannot be 
determined at this time. 

Pathology. — The verrucous process begins with downward and 
upward growth of the rete-cells, resembling in this respect benign 
epithelioma. The granular layer is remarkably thickened, while the 
greatly hypertrophied horny layer is less compact than normal owing 
to imperfect keratinization of the cells, in many of which the nucleus 
is still apparent. The descending rete-processes are usually pointed 
and turn toward a common centre, producing thus a shallow cup-shaped 
depression in the cutis. 

The papillae beneath the wart are flattened, many being obliterated, 
except a few at the centre of the base. These hypertrophy, become 
elongated, and with their dilated vessels form a vascular " core " for 
the verruca. In the pointed forms the connective-tissue and vascular 
elements are marked, while the horny layer is but slightly hyper- 
trophied. In verruca plana the chief change is in the rete, the horny 
layer being but little thicker than normal. 

The seborrhoic wart is characterized by a thickened horny layer 
and hypertrophied rete, with grouped and linear epithelioid cells sepa- 
rated by bundles of connective tissue in the papillary and subpapillary 
layers. The coil-glands are fat-infiltrated, as also parts of the rete and 
cutis (Pollitzer 2 ). In verruca acuminata there is no tendency to corni- 
fication. The rete and papillary bodies are remarkably hypertrophied 
and macular. 

Diagnosis. — It is a matter of importance to recognize the fact that 
many epitheliomas begin as warts ; therefore the verruca of those ad- 
vanced in years should always be examined and treated with a view 
to this fact. A tendency, especially in the aged, for the lesion to break 
down into an ulcer should arouse suspicion. Warts on the face and 
the backs of the hands of the aged are often of this class. 

Another class of warts are tuberculous in character, and, whether 

1 Verhand. der v. deutschen. Cong., 1896, p. 497 (bibliography). 

2 Brit. Jour. Derm., 1890, ii., p. 199. 



VERRUCA. 



519 



occurring in the young or the aged, are the result of infection with 
tubercle-bacilli, a generalized tuberculosis at times originating in these 
lesions (vide Tuberculosis Verrucosa). 

Great care must be had to distinguish the moist variety from syphi- 



Fig. 54. 




Vertical section of the summit of a pointed wart : a, papilla containing vascular loop ; c, stratum 
corneum ; d, hypertrophied rete. (After Kaposi.) 



litic condylomata. In the latter there is usually a history of conta- 
gion with other syphilodermata upon the surface, such as mucous 
patches, palmar lesions, or papules of the face. Fibroma, or mollus- 
cum fibrosuin, generally occurs in tumors of greater number, firmer 
consistence, and larger size. The tumor of molluseum epitheliale 



520 HYPERTROPHIES. 

greatly resembles a wart, but the waxy- whitish appearance of the 
lesion and its dark punctum at one plane or another sufficiently dis- 
tinguish it. In exceptional cases verruca plana may in shape and 
grouping closely simulate lichen planus, but the location and history, 
together with the absence of the typical color, the varnished appear- 
ance, and of the itching, characteristic of lichen planus, will make the 
diagnosis clear. 

Treatment. — Crocker, Colrat, Thin, and other writers still teach 
that there is an eifective treatment of warts by the administration 
internally of magnesium sulphate in repeated doses, liquor arsenicalis, 
nitro-muriatic acid, the tincture of thuya, and thyroid extract. Warts 
may be removed by excision, erasion, or caustics (silver nitrate, alkalies, 
acids, ferric chloride, corrosive sublimate, etc.). The larger growths 
upon the genitalia that are often highly vascular may demand the 
prior application of a ligature when they are pedunculated. Even the 
slender filiform warts will be found to contain a small vessel in each 
pedicle that requires cauterization after excision. Ordinary venereal 
warts require scrupulous cleanliness, deodorization with chlorinated 
soda, and afterward dusting with calomel or with powders of inert 
material (fuller's earth, lycopodium, talc) containing 10 per cent, of 
salicylic acid, alum, or tannin. When warts cannot more readily be 
removed by the knife or by curved scissors the Paquelin cautery may 
be used. The blackened eschar which is left prevents hemorrhage, 
serves as the best subsequent dressing, and is less likely to be followed 
by a return of the growth. In some cases it is a useful expedient to 
transfix the lesion in several directions with the long needles used in 
gynaecological practice, previously dipped in a 50 per cent, solution of 
chromic acid. 

One may also transfix the base of the wart a sufficient number of 
times with a needle connected with the negative pole of a galvanic 
battery, the positive pole being connected with the body of the patient 
by the aid of a moist sponge. 

The formula according to which are made several of the proprietary 
" wart-cures " sold in the shops is as follows : 



R Acid, salicylic, 3ss ; 

Cannabis Indie, extr., gr. v ; 

Collodion., gss ; 15 



33 
M. 



Sig. To be painted over the wart with a camePs-hair brush. 
For small multiple warts Morris recommends the following : 



Glycerin. > 


3jss ; 


6 


Acid, acetic, dil., 


Sijss ; 


10 


Sulphur, praecipit., 


3j; 


4 



M. 



For patches of warts Van Harlingen recommends cautiously attack- 
ing one part at a time with the following paste : 



R Pulv. acid, arseniosi, gr. vj ; 



40 
M. 



VERRUCA. 521 

Glacial acetic acid, carbolic acid, nitric acid, chromic acid, caustic 
potash, zinc chloride — in fact, the entire list of caustics — have been 
successfully used in these destructive applications. 

Warts may also be treated by painting once daily with a saturated 
solution of potassium bichromate in boiling water. The liquid is 
applied cold. The application is painless and leaves no scar (Louvel- 
Dulongpre). Seborrhoic warts usually are treated with shampooings 
and cinnabar and sulphur pastes, 1 part of the first, 20 of the second, 
and 50 of paste. In two cases in our care of numerous and grouped 
verruca plana in young adults, rubbing the lesions daily with Vlem- 
inckx's solution was followed by their complete disappearance in two 
weeks. 

For warts not requiring operative removal local treatment generally 
answers well. Those about the genital region often disappear if per- 
sistently washed with a solution of tannin in alcohol, 1 drachm (4.) to 
3 ounces (96.), after which they are dried and thoroughly dusted with 
boric acid, or salicylic acid with lycopodium, or burnt alum and rosin, 
or, what is most popular, dry calomel. Alum- and lead-lotions may 
also be substituted for the tannin and alcohol, and for a time be kept 
over the parts on a compress. 

Warts are also removable in some instances by radiotherapy, using 
a soft tube, after relatively few exposures. 

Prognosis. — Warts are benignant growths ; in childhood and in 
early adult life they need not suggest grave sequels. It is far different 
in advanced years, for, though these excrescences possess even then no 
malignant character, they are frequent precursors of epithelioma. 
While it may justly be urged that the early lesions in such cases were 
really epitheliomatous and not verrucous, the fact remains that many 
warty formations of apparently benign character do in advanced years, 
especially when irritated by frequent caustic applications, undergo a 
cancerous metamorphosis. The tuberculous wart also may become the 
source of general tuberculous infection. 

Multiple Cutaneous Tumors accompanied by Intense Pru- 
ritus. — Under this title Hardaway, of St. Louis, described a rare 
disorder characterized by the occurrence of about sixty pea- to nut- 
sized, dense tubercles and tumors covered by a thickened, scaly, and 
excoriated, often hemorrhagic skin. In some situations coalescence 
had occurred, forming thus long and narrow plaques of nearly the 
width and of half the length of the finger of an adult. The lesions 
were seen upon the outer aspects of the arms and legs, the palms and 
soles, the sides of the fingers, and around the ankles, wrists, and 
elbows. The accompanying pruritus was intense and intolerable ; and, 
having lasted for twenty-two years, it was associated with the degree 
of pigmentation often observed under similar conditions. The patient, 
who was an unmarried woman, fifty-one years of age, declared that 
the lesions first appeared as " blisters." 

Specimens of these tumors, microscopically examined by Heitzmann, 
exhibited hyperplasia of the epithelial and connective tissues. The 
papillae were longitudinally elongated, branching, and provided with 



522 HYPERTROPHIES. 

narrow capillaries. Numerous nests, greatly varying in size and con- 
taining inflammatory elements with considerably enlarged blood-vessels, 
lay close beneath the papillary layer of the corium. These elements 
showed all stages of transition into basic substance. The deeper layers 
of the derma were built up of very coarse bundles of connective tissue 
and of numerous elastic fibres. 

Synovial Lesions of the Skin. — These cutaneous lesions possess 
importance from a diagnostic point of view. We have observed them 
in several individuals in whom the exact nature of the disorder had 
not been understood. They occur in the form of wart-like projections 
from the skin, pseudo-vesicles, and bullae, always over the site of bursa? 
connected with tendons, traversing the small articulations of the hand 
and foot. They are seen over the metatarso-phalangeal articulations ; 
and in the hand most frequently over the dorsal face of the articulation 
between the distal and adjacent phalanges of the index-finger and 
thumb. The first form is that of a roundish, corneous, pea-sized wart 
with a yellowish centre, of long duration, usually insensitive unless 
roughly handled. When punctured a syrupy, yellowish, or grumous 
fluid exudes, which continues to form after repeated puncture. Split- 
pea-sized vesicles, and bullae as large as a small coin, often exceed- 
ingly painful, are also seen, especially upon the feet, with simply an 
epidermic roof- wall. Each lesion contains the same thickened, yel- 
lowish or whitish fluid, occasionally mingled with masses like sago- 
grains. In every case the contents of the lesions are supplied by a 
synovial bursa beneath the skin, with which the lesion is either directly 
connected or in communication by a short sinus. The treatment 
requires the complete excision or destruction of the secreting cyst-wall. 

Sidney Jones and Makins, of St. Thomas Hospital, exhibited several 
lesions of this character to the London Pathological Society. 

Papilloma (Acanthoma). — This term has loosely been applied 
to a large number of cutaneous growths widely differing from each 
other, both histologically and clinically. It has been made to include 
the vegetations of a cauliflower or papillomatous aspect which may 
occur in syphilis, carcinoma, lupus, and other disorders. It also is 
applied to warty lesions of this type. The term has no pathological 
significance. 

Papilloma Area Elevatum (Beigel) is regarded by Crocker as 
an illustration of the results of the ingestion of one of the bromine 
salts, and this is well corroborated by the picture presented by one of 
our patients, in whom the face was covered with so-called " papil- 
lomatous " growths as a result of the administration of the salts of 
iodine. 1 

Papilloma Neueoticum is a term which has been applied to 
ribbon-like growths classed by some authors with ichthyosis hystrix. 

*.y properly belong, however, to the category of linear nsevus. 

matitis Tuberosa due to Ingestion of the Iodine Compounds," Med. News, 
r.% o. 411 ; illustrated in color from a painting in oil. 



h 

irfi 



PLATE XII 






Nsevus Lipomatodes. 



N&VUS PIGMENTOSUS. 523 

NJEVUS PIGMENTOSUS. 1 

( Lat. ncevus, a mask. ) 

(Pigmentary Mole ; N^evus Spiltjs. Ger. } Fleckenmal, 
Linsenmal ; Fr. } Tache pigmentaike.) 

Pigmentary moles are eircum scribed accumulations of pigment in 
the skin, developing with and without other tegumentary alteration. 

Symptoms. — Abnormal congenital pigmentations of the skin vary 
in color from a light-yellow or chocolate-brown to a blackish hue, and 
they may be single, or be multiple and very numerous. They vary in 
size from that of a pinhead to that of tumors of large volume ; and 
are either ovoid or circular in contour, or are so irregularly shaped as 
to present a fanciful resemblance to lower animals, whence the popular 
belief as to their origin in maternal impressions. They occur in both 
sexes, and in all regions of the skin, but especially upon the face, neck, 
trunk, thighs^ buttocks, and external genitals/ The term Kzevus 
Spiltjs is applied to those pigmentations which occur in a smooth and 
otherwise unaltered skin; N^vus Verrucosus, to those which are 
warty, soft or hard, furrowed or smooth, accompanied by hypertrophy 
of the papilla?, and often presenting a growth of hair ; N^evus Pilosus, 
to those surmounted by a growth of shorter or longer, stiff or downy, 
dark- or light-colored hairs ; and Njevus Mollusciformis, or Lipo- 
matodes, to the soft or firm, more or less elevated, fatty and projecting 
tumors. 2 A case of unusually large congenital nsevus lipomatodes 
associated with multiple pigmentary nsevi of several forms, occurring 
in a child observed by one of us in 1883, 3 is represented among the 
illustrations of this treatise. The so-called " White Moles " are 
similar to those described above, except that the pigmentation is slight 
or apparently wanting. 

Linear N^vus (Morrow), 1 N^vus Unius Lateris, N.evus 
Verrucosus, N^vus Nervosus, Njsvus Lichenoide, Ichthyosis 
Cornea, Ichthyosis Linearis Neuropathica, Papilloma Neu- 
ropathicum Unilaterale. — Moles may be, when multiple, sym- 
metrically or asymmetrically developed upon the surface of the body ; 
and in either case may exhibit an arrangement suggesting the control- 
ling effect of the nervous system. 

In a case reported by one of us 2 there were multiple monolateral 
pigmentary nsevi distributed over the left side of the trunk in the 
course of the intercostal nerves, and in such a manner as strongly to 
suggest to the eye their correspondence in site with the lesions of 
zoster of the same region. De Amicis 6 had previously reported a 

1 For studies of the different forms of nsevi, and full bibliographies, see Moller, 
Archiv, 1902, lxii., pp. 55 and 371 ; and Eiecke, Ibid., 1903, lxv., p. 65. 

2 For a study of the soft pigmented moles, see Whitfield, Brit. Jour. Derm., 1900, 
xii., p. 267 (bibliography) ; Judalewitsch, Archiv, 1901, lviii., p. 15) with critical 
survey of literature) ; Fick, Archiv, 1902, lix., p. 323 (bibliography) ; and Sachs, 
Ibid., 1903, lxvi., p. 101 (full bibliography). 

3 Jour. Cutan. Dis., 1885, iii., p. 193. 
* N. Y. Med. Jour., 1898, lvxii., p. 1. 

5 Chicago Med. Jour, and Exam., 1877, xxxv., p. 377. 

6 Lo Sperimentale, 1876. 



524 



HYPERTROPHIES. 



somewhat similar case. Many other cases have been recorded in 
which pigmentary and verrucous nsevi, consisting of variously sized 
and shaped lesions, were arranged in lines or streaks, usually on one 
side only of the body, and often along the course of one or more nerves. 
Selhorts l and Thibierge 2 have reported cases of this type in which 
involvement of sebaceous glands produced acneiform lesions. 

Fig. 55. 




Nsevus linearis. 

Etiology. — Moles occur in both sexes either as congenital lesions 
or developing later in life. In both cases they may persist without 
change or undergo degenerative transformation at a later period. The 
explanation of the distribution of these lesions, either along the course 
of nerves, vessels, the lines of skin-cleavage, the lines bounding the 
nerve-territories (Yoigt), the embryonic sutures, or the metamenes of 
the body, has studiously been sought. 3 

1 Brit. Jour. Derm., 1896, viii., p. 419. 

2 Annales, 1896, s. 3, p. 1298. For full review of the subject, with bibliography, 
see Werner and Jadassohn, Archiv, 1895, xxxiii., p. 341 ; also Strasser, Archiv, 1903, 
lxxx., 21 (bibliography). D. W. Montgomery gives a list of 48 titles under which 
linear nsevus has been described, Jour. Cutan. Dis., 1901, xix., p. 455. 

3 Of. D. W. Montgomery, loc. cit., and Balzer and Alquier, Arch. gen. de Med., 
1901, clxxxvii., p. 717. 



NAEVUS PIGMENTOSUS. 525 

Naevi seem to occur with equal frequency in the two sexes, and 
though they usually appear at birth or soon after, they are sometimes 
first seen at puberty or even later in life. It is possible that they may 
be acquired after birth, as claimed by some authors; but it is much 
more probable that such presumably acquired cases are instances of 
rapid development from minute congenital pigmentary moles. 

The tendency of pigmentary naevi, after attaining full evolution, 
is to persist unchanged for a lifetime. Their increase in persons of 
tender years is occasionally characterized by a relative rapidity of 
growth. A pilary naevus upon the cheek of an infant may extend over 
nearly double its original area in the course of two years. In adults 
an increase in the size of these growths is unusual but does sometimes 
occur. Degenerative changes are possible. In the young there may 
be spontaneous gangrene or rapid necrosis following slight injury of the 
naevus. In older people there may be a malignant transformation into 
carcinoma or pigmented sarcoma. 

Pathology. — Anatomically, pigmentary moles are readily separable 
into two classes : first, those in which the pigment only of the skin 
undergoes hypertrophy (nsevus spilus) ; second, those in which there is 
always hypertrophy of the epidermis, together with a varying amount 
of hyperplasia of the papillae, vessels, glands, or hair-follicles. The 
histopathology thus varies greatly in different cases, depending upon 
the extent to which these different elements of the skin are involved. 
The distinction made by v. Barensprung, Gerhardt, and others between 
these two classes and still a third, in which the lesions are limited to 
the cutaneous regions supplied by one or several nerves (linear naevus, 
etc.) is more apparent than real : for there is probably a trophoneurotic 
influence exerted in all cases, even in the enormous tumors of a mol- 
lusciform type. According to Demieville, the pigment-accumulation 
occurs in the corium as well as in the epidermis, in the form of ribands 
stretching along the lines of the blood-vessels. Kaposi holds that 
moles as well as naevi result from a retained foetal impulse to develop- 
ment on the part of the cellular elements of the naevus, which carries 
them beyond the normal limits of growth. 

Treatment. — Pigmentary moles very rarely spontaneously disap- 
pear. Their removal may be accomplished by excision, or by destruc- 
tion with caustics, with the Paquelin knife, or with the needle by elec- 
trolysis. The last-named method is applicable only to the smaller and 
more superficial growths of this class. Fox 1 calls attention, in connec- 
tion with this subject, to the need of passing the needle no deeper than 
the epidermis, sufficiently deep merely to " blister the surface of the 
black spot." The electrolytic removal of hairs from hairy moles usu- 
ally results in obliteration of the lesion. This operation should be 
conducted in accordance with the rules formulated for the electrolytic 
treatment of hypertrichosis in general. Radiotherapy has been em- 
ployed by us in a few cases of pigmentary naevi with slight improve- 
ment in one case. 

Prognosis. — Pigmentary moles, when not removed artificially, 
rarely increase in size, thus not adding to the disfigurement they 
1 Electricity in Removal of Superfluous Hairs, etc., Detroit, 1886. 



526 HYPERTROPHIES. 

occasion. The possibility of the metamorphosis of these lesions into 
malignant growths after the attainment of advanced years is the chief 
element of gravity. 1 

ACANTHOSIS NIGRICANS. 

Under this title Pollitzer and Janovsky 2 describe cases which at 
present it is difficult to recognize as instances of ichthyosis, of verruca, 
or of naevus pigmentosus. Morris, 3 Pye-Smith, Darier, Spietschka, 4 
and others 5 have since reported cases, numbering in all about thirty. 
In these patients, after an insidious or rapid evolution of symptoms, the 
neck, the mouth, parts of the trunk, genitocrural and anal regions, 
hands, axillae, and thighs display yellow and grayish-brown to almost 
black pigmented areas, covered in some places by fine papillary pro- 
jections, some of which are scattered and discrete, while those situated 
in the axillae, the groins, and the flexor surfaces of the joints are 
grouped and coalesce to form papillomatous, vegetating masses. In 
places there is simple exaggeration of the natural lines of the skin, 
in other parts there are ridges radiating from a central point. The 
mucous surfaces also are involved. Over the hands of one patient 
the color was deepest along the lines of the veins ; and there was a 
glassy shimmer to the prominent normal areas of the cuticle. In 
Morris's case the pigmentation and warty growths were not always 
associated, there being a few sites of pigmentation in an otherwise 
normal skin, or in which there were unpigmented warty growths. 
Freckles, seborrhoic warts, and pigmentary naevi frequently surmount 
the pigmented area. In some cases epithelioma has resulted (uterus, 
stomach, mamma, liver). 

Etiology. — Women are affected more frequently than men, the ages 
of the patients ranging from the first to the eighth decade. The dis- 
ease is supposed in some cases to be related to the carcinomatous state. 

Pathology. — In sections made of the skin removed from one patient 
there were recognized dilatation of the bloodvessels and lymph-spaces 
in the papillary and subpapillary layers ; increase of pigment-cells ; 
enormous thickening of papillae and epidermis ; elongation and bifur- 
cation of the rete-pegs, and some " suggestions " of epithelial pearls. 
A few colonies of bacilli having the shape of short, thick rods were 
discovered, but not in all the secretions examined. In several cases 
the condition has been associated with abdominal carcinoma. 

1 Of. Whitehead, Johns Hopkins Hosp. Bull., 1900, xi., p. 221 (full bibliography) ; 
and Whitfield, loc. cit. 

2 Internat. Atlas, 1890, iv., ii. * 

3 Med.-Chir. Trans., 1894, lxxvii., p. 305. 

4 Archiv, 1898, xliv., p. 247. 

5 For bibliography, see Darier, La Pratique Dermatologique, i., p. 183 ; and Pawl of, 
Monatshefte, 1902, xxxiv., p. 269. 



ICHTHYOSIS. 527 

ICHTHYOSIS. 

(Gr. IxOve, a fish.) 

(Fish-skin Disease, Xeroderma. Ger., Fischshuppenausschlag ; 
Fr., Ichthyose ; ItaL, Ittiosi.) 

Ichthyosis is a congenital cutaneous deformity, characterized by a 
dry, harsh, and scaling condition of the skin, associated with abnormal 
cornification of its external layers. 

Symptoms. — Ichthyosis Simplex (Xerosis; Xerodermia). — 
The earliest and mildest form of ichthyosis simplex is the xeroderma- 
tous condition. 

The sole symptoms are cutaneous. The skin of the body, in some 
regions more than others but at times universally, is to the touch dry, 
harsh, rough, and destitute of natural moisture and unguent. Closely 
inspected, the skin-surface is seen to be scaly, exfoliation being of the 
character described as furfuraceous, and often inelastic and leathery. 
In some cases the hand passed briskly over the surface of such a skin 
will cause separation of scales in a scanty shower ; in other cases the 
flakes of epidermis are attached more or less, and the clothing of the 
patient is not, as in some forms of psoriasic and pityriasic disease, 
covered with epidermal scales. In brief, there is not in progress a 
catarrh of the horny layer, as in some of the other disorders named ; 
but there is merely an unusual keratinic transformation of the elements 
of that layer. 

The parts chiefly involved are the extensor faces of the extremities, 
as also the hands, feet, forearms, and legs ; but all parts of the skin 
may be involved, including the scalp, face, temples, cheeks, and even 
the lips. 

The disorder is met with in all grades, from the mildest physiological 
dryness suggestive of so-called " goose-flesh," to that state in which 
the face only indicates an abnormal condition of the skin. In some 
cases the xerodermatous papillae project as in keratosis pilaris. The 
color of the integument in well-marked cases is of a dirty-yellowish or 
dirty-brownish shade, suggesting an unwashed condition, and in ex- 
treme cases, usually those of older patients, the skin becomes rather 
deeply pigmented. The affection is seen in both sexes and at all ages, 
being a congenital condition, the first appearance of which is indicated 
clearly only after variable periods of time after birth. Red-haired 
individuals perhaps furnish the larger number of well-marked cases. 
The general health is unaffected. Before puberty the affection in 
northern latitudes will often be inappreciable in summer and distinct 
in winter. As maturity is reached, however, the condition may become 
permanent. 

A child affected with what appears at first to be merely xerosis may 
exhibit an extreme type of ichthyosis before puberty, while another 
will go through life the xerosis of his childhood remaining practically 
unchanged. 

The xerodermatous skin both of children and adults is commonly 



528 



HYPERTROPHIES. 



sensitive to irritating agents, and is often the seat, especially in severe 
winter weather, of itching, inflammation, fissures, etc. 

In a grade of ichthyosis more advanced the scales are massed, form- 
ing grayish and whitish, polyhedral elevations or plaques, regularly 
outlined and closely set, especially upon the extremities and certain 
portions of the trunk. It is the regular setting of these horny plates 
which has given the malady its familiar title, fish-skin disease. The 
scalp in almost all cases is dry and scaly and the hairs like those 




Ichthyosis hystrix. 

recognized in long-standing seborrhoea sicca of the same region. The 
so-called " Alligator-skin " represents an extreme condition of corni- 
fied integument, inelastic, discolored, and transformed into a cuirass 
covered with thick plates like those of the saurian. Elsewhere the 
scaliness described above may be present, but in a more marked degree. 
Follicular keratosis is a common feature. Variations occur, in conse- 
quence of which the plaques, bordered distinctly by the natural lines 
and furrows of the skin, are even depressed, centrally or completely, 



ICHTHYOSIS. 



529 



or they assume darker shades of color — viz., brownish and greenish- 
brown. 

Ichthyosis Hystrix. — With and without the symptoms detailed 
above, the hypertrophy of the skin may, in circumscribed patches 
or larger areas, produce irregularly shaped, verrucous, corneous, 
corrugated, wrinkled, or rugous masses, usually much darker in color 
than the patches of ichthyosis simplex, and more often also dis- 
covered in adult years. The resemblance is here rather to the rough 
bark of a tree than to the scales of a fish. In still rarer cases the 
excrescences assume a spinous, acuminate, or horn-shaped form. 
The hand passed over the skin-surface perceives not only the excessive 
roughness, but also the dryness of the skin. Perspiration in some 
cases is imperceptible in the parts affected. The nails are friable and 

Fig. 57. 




Ichthyosis hystrix, vertical section : a, masses developed from the stratum corneum ; b, cones 
formed by the re'te ; c, hypertrophied papillse with dilated vessels; d, dense connective tissue of 
corium, exhibiting numerous vessels transversely divided. (After Kaposi.) 

indurated ; the scalp is scaly and covered with hairs of exceeding 
harshness. The palms and soles are often spared. Kaposi describes 
certain diffuse callosities occurring in the palmar and plantar regions 
differing from ichthyotic patches elsewhere. The face is usually spared, 
but, when involved, only the slighter manifestations o^ the disease appear 
there — minute, superficial, scaly patches of a grayish tint. 

Later studies of the hystrix type of ichthyosis have led to a modi- 
34 



530 HYPERTROPHIES. 

fication of the view formerly held. To-day many disorders to which 
the name ichthyosis hystrix once was given are classed with keratosis 
palmaris et plantaris, congenital warts, " psorospermosis follicularis," 
nsevus unius lateris, and other similar affections. 

Ichthyosis Congenita 1 (" Harlequin" Fcetus, Keratosis 
Universalis Congenita). — This exceedingly rare deformity occurs 
as an intra-uterine modification of the skin of the foetus, which usu- 
ally is brought into the world as a non-viable monstrosity. The skin 
is represented by a thick, horny cuirass, deeply furrowed and resem- 
bling plates of armor. Large flakes of corneous epidermis, but par- 
tially attached to the corium, present their broad free edges to the outer 
world. The ears, eyelids, and lips usually are wanting, being replaced 
by corneous folds suggesting in appearance the corresponding features 
of a mummy. The fingers and toes resemble talons and claws. Death 
commonly occurs in the course of a few days from inability to secure 
nutrition by the act of sucking and from imperfect development of 
other organs than the skin. Bowen 2 believes that some of these de- 
formities are due to a persistence of the epitrichial layer of the foetus. 

Sherwell 3 describes a case of congenital ichthyosis of unusual in- 
terest from the fact that at the time of the report the infant had lived 
to be more than five months old, and seemed to be gaining in strength 
-and improving in the condition of the skin. No history of heredity or 
of a family tendency to deformities of the skin could be obtained. 

Ichthyosis Lingile (" Psoriasis of the Tongue") is a dis- 
order described by the French under the title leucoplasie. It is not a 
variety of ichthyosis. (Of. Lichen planus of the mucous membranes.) 

Variations from the types described above are noted by observers. 
Hibert 4 for example, in a case of congenital circumscribed ichthyosis 
in a young woman, discovered a growth of thick hairs, one centimetre 
long, over the left shoulder and arm. Weisse 5 exhibited to the New 
York Dermatological Society a boy, ten years old, with hemorrhagic 
fissures in an ichthyotic skin, double ectropion, corneal opacities, claw- 
like fingers, attachment of the ears to the sides of the head, and a gen- 
eralized condition of the skin which became very red when warm, some 
doubt however existing as to the diagnosis. Extreme types of ich- 
thyosis are seen in the so-called " porcupine," " rhinoceros," or " hedge- 
hog" patients. In these unfortunate beings the entire skin is con- 
verted into a rugged, bristling, warty, quilled, or horn-like envelope, 
suggesting the integument of the animals named. The terms Ichthyosis 
Serpentina, Nacrea, and Nigricans are employed to designate those con- 
ditions, respectively, in which is recognized a snake-like appearance of 
the skin, silvery whiteness of the scales, or a dark pigmentation. 

Viewing ichthyosis as thus exhibited in various manifestations, it 
is seen to be a congenital deformity rather than a disease. It may be 
partial or general, though usually the latter, with intense manifestations 

1 For bibliography, see Neumann, Archiv, 1902, lxi., p. 163 ; and Lenglet, Annales, 
1903, s. iv., iv., p. 369. 

2 Jour. Cutan. Dis., 1895, xiii., p. 485. 

3 Ibid., 1894, xii., p. 385. 

4 Virchow's Archiv, 1884, xcix., p. 569. 

5 Jour. Cutan. Dis., 1883, ii., p. 49. 



ICHTHYOSIS. 531 

over the extremities, especially over the extensor aspects ; and relative 
immunity of the face, the axillae, the groins, the flexor aspects of the 
limbs, the palms and soles, the glans penis, and the prepuce. The 
deformity is rarely visible at birth, but usually becomes apparent before 
completion of the first year of life. It is manifested first in the regions 
of election named above — i. e., over the elbows and the knees — and 
here it may for some years only be apparent in northern latitudes in 
winter, disappearing almost wholly in the summer season. When 
maturity is reached, the deformity has been known to disappear tempo- 
rarily under the influence of intercurrent disease (variola). One patient 
is said to have regularly cast a slough of his integument in the autumn. 
The general health usually is unimpaired. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these patients may be free from the eczematous and 
other complications of the less diffuse keratoses. In four ichthyotic 
patients who were syphilitic there was a decided tendency to the pro- 
duction of lesions of the mucous surface without cutaneous efflorescence. 
The extensors usually are implicated more than the flexor surfaces of 
the extremities. 

Etiology. — Ichthyosis is unquestionably a congenital disease, though 
its first manifestations are apparent only during the second year of life. 
Crocker describes an acquired case in a septuagenarian. It is said to 
be invariably hereditary, but this should be accepted with some reserve. 
One ichthyotic patient, married to his cousin, had by her five children 
free from cutaneous disease. None of his parents or grandparents was 
affected similarly. The disease occurs equally in both sexes, in all 
lands, and in persons of all social ranks. It is liable to aggravation 
in cold climates and during the season of winter. The general vigor 
and development of patients thus deformed are, as a rule, unimpaired. 
Kaposi says : " The cause appears to be a local anomaly of the nutri- 
tion of the skin, especially involving its epidermic and fatty elements." 

Thost * describes ichthyosis occurring in four generations. Accord- 
ing to the ascertained genealogy, the ancestor first known to have suf- 
fered from this affection had five male children who inherited it, while 
one girl and one boy were spared. One of these affected subjects had 
five children, of whom three males showed the anomaly, while one boy 
and one girl remained free. Another brother, of the second genera- 
tion, had five male and three female children ; of these, four boys and 
two girls became affected. One of the latter (of third generation) 
bore four children, of whom three girls inherited the disease, while the 
fourth, a boy, escaped. It appeared that the affection always showed 
itself within a few weeks after birth, in the form of a roughness of the 
palmar and plantar surface. With the growth of the patient the con- 
dition constantly increased in severity, the epidermis shedding in large 
shreds, until the disease reached its maximum by the fourteenth year. 
There was a marked disposition to excessive sweating, particularly in 
the diseased localities ; the sensibility of the skin remained normal. 
Microscopic examination showed, in addition to hypertrophied papilla?, 

5 Inaug. Diss., Heidelberg, 1880 ; Centralbl. f. Chir., 1881, xiii., p. 154. 



532 HYPERTROPHIES. 

great development of the sweat-glands, with marked thickening of the 
ducts. Treatment failed to give more than partial relief. 

In the Molucca Islands and some other isolated regions ichthyosis, 
on account of its unusual prevalence, has been regarded as an endemic 
affection ; but instances of this kind are readily explained, without 
referring to climatic influences, by the operation of heredity and inter- 
marriages. 

Pathology. In the mild forms Unna describes an immediate for- 
mation of the horny layer from the rete without the intervention of 
keratohyalin. It is a complete cornification, the horny cells being 
homogeneous and containing no nuclear remnants. In this respect 
the hyperkeratosis is unusual, and contrary to the belief of many 
observers that cornification is impossible without the intervention 
of the keratohyalin of the granular layer. The rete is thinned more 
from an atrophic condition of the cells than from an actual diminution 
of their number, though this does occur sometimes, so that only one or 
two layers of cells cover the papillary tips. The lymph-spaces are also 
very small. The extremities of both the rete-pegs and papillae are 
broad and flattened and their necks narrowed, so that they suggest a 
dove-tailed appearance. The coil-glands possess a swollen epithelium 
and a widened lumen resembling their excretory ducts, which exhibit 
less functional activity. The collagenous fibres are thickened at the 
expense of elastic, fatty, and lymphatic structures, and there may 
be a chronic low grade of papillary and perifollicular inflammation 
without plasma-cells and with only a few mast-cells. The follicle- 
mouths either were dilated with a broad horny plug, or were closed, 
retaining the plug in the dilated neck. In severe forms is noted a 
proliferating rete with reappearance of the granular layer and a deeper 
dipping down of horny substance, the cutis containing many plasma- 
and mast-cells. In these severe forms there is less superficial exfolia- 
tion, the dryness characteristic of the mild forms is wanting, and the 
condition is readily transformed into the clinical crusting type known 
as " ichthyotic eczema." 

Ichthyosis hystrix has, according to Kaposi, the anatomical structure 
of all warts. Crocker finds that the lesions differ from plane warts in 
that the horny formation dips down deeply along the papillae. 

Ichthyosis congenita is believed by Bowen 1 to be due to a per- 
sistence of the epitrichial layer of the foetus. Wassmuth 2 has pub- 
lished the results of a study of a case of ichthyosis congenita (hyper- 
keratosis diffusa congenita). He found the changes limited almost 
entirely to the epidermis, the cutis showing only an insignificant chronic 
inflammation of low grade. As compared with normal skin, the pap- 
illae were much more numerous, broader and flatter, with greater irregu- 
larity in form and size. The layers of the rete were thickened and the 
cells of the epithelial pegs assumed a spindle form. Nearer the surface 
they became polygonal. A granular layer could be made out definitely 
only on the scalp. The horny layer varied in thickness on different 
portions* of the body, but averaged two hundred times thicker than 

1 Jour. Cutan. Dis., 1895, xiii., p. 485. 

2 Beitrage zur path. Anat. und allgemein. Path., 1899, p. 19. 



ICHTHYOSIS. 533 

normal". The sweat-glands were greatly increased in number, but 
otherwise normal. Deformities of the sebaceous glands were caused 
sometimes by keratinization of the follicle-mouths. The hairs grew 
quite normally except for their deformed shape, caused by the thick 
and dense horny layer. 

Diagnosis. — Ichthyosis not only presents features which are so 
characteristic as to be unmistakable, but also those which can be well- 
nigh perfectly portrayed in plates. In this respect it differs from a 
long list of cutaneous maladies. 3 

Whenever necessary in the establishment of a diagnosis, aid of an 
important character can be obtained in the history of the disease and in 
recognition of the absence of the lesions and lesion-sequels exhibited in 
the exudative and scaling affections heretofore considered. The most 
conspicuous characteristic of ichthyosis as distinguished from psoriasis, 
lichen ruber, and pityriasis, is the absence of inflammatory phenomena. 

Treatment. — The younger the patient applying for relief the larger 
are the chances of improvement and of possible recovery. Ichthyosis 
hystrix of mature years is far less manageable. Internal treatment is 
valueless, though authors still recommend sulphur, thyroid extract, 
antimony, and jaborandi. 

External treatment is directed to softening, macerating, or anointing 
the skin, and, so far as practicable, to preserving it in a softer state. 
This softening is accomplished by frequent baths, alkaline, vaporous, 
or combined with the use of soap or green soap, and generally followed 
by an anointing with vaselin, dilute glycerin, or lard. The French, 
after the removal of the denser layers of the horny plates with the aid 
of soft soap and water, anoint the body by friction with glycerolate of 
starch. Almond-, cod-liver, linseed-oil, benzoated lard, lanolin, or, 
even better, salieylated cocoanut-oil may be used after the bath. Stel- 
wagon and others recommend the addition of resorcin to the unguents 
in the strength of 3 to 10 per cent. Sulphur and ichthyol salves 
have also been praised. Only by the most assiduous perseverance is 
a desirable result obtained and permanently secured. In the severe 
hystrix varieties the most annoying projections and rugosities may be 
removed by excision, by the Paquelin knife, or, less preferably, by the 
aid of caustics. 

Subcutaneous injections of 1 grain (0.06) of pilocarpine have been 
practised in ichthyosis, in order to induce sweating, with a view to 
maceration of the skin. Van Harlingen recommends the following for 
use when the epidermis begins to shed after the application of soft soap : 



R 



Potass, iodid., 




9 j ; 


i 


01. pedis bubuli, 
Adipis, 


} 


i aa ^ss ; 


aa 15 


Glycerin., 




5h 


4 



33 



M. 



Anderson recommends the wearing of pure vulcanized India-rubber 
garments, a method of treatment too exhausting for all cases. 

Taking a general survey of the therapeutic management of ichthy- 
osis and its results, the course to be advised for the majority of patients 
1 Cf. portrait of the ichthyotic skin in Plate F of Duhring's Atlas. 



534 HYPERTROPHIES. 

is clear. With but few exceptions, the subjects of this deformity are 
either entirely relieved or greatly better during hot weather and in 
moist atmospheres. Marked exceptions to this rule, however, occur. 
Under these circumstances, and having regard to the essential fact that 
the deformity is lifelong in duration, patients should always, when prac- 
ticable, select for permanent residence a climate most conducive to the 
comfort of the skin. There is no step which the ichthyotic patient can 
take comparable in value with the selection of a suitable environment. 
Prognosis. — Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with respect 
to a " cure " of the deformity. Treatment, persistent, prolonged, and 
properly directed in connection with suitable climatic influences, may 
do much to improve the condition of the skin. 

ONYCHAUXIS. 1 

(Gr. bvvt;, a nail ; avgeo, to grow.) 

(Hypertrophy of Nail.) 

Symptoms. — This may be a congenital or acquired disorder. The 
nail-substance may be developed to an unusual extent either as an idio- 
pathic or as a symptomatic affection, and in each case the nails may simply 
be increased in volume, extent, or number, or may exhibit such increase 
in connection with secondary changes. Thus, the nail may develop to 
an extraordinary length or breadth, preserving its general character as 
regards texture, color, and position ; or it may also be changed in any 
particular, becoming opaque, discolored, dirty yellowish, and blackish 
or brownish ; rugous, furrowed, horny, and rigid ; thickened in one 
part and thin, vitreous, and extremely fragile in another; tilted to one 
side or the other on its bed ; or projected backward in recurved, 
irregular lines. Finally, the matrix may be inflamed, suppurating, 
hemorrhagic, or the seat of an excruciating pain. One or more of the 
nails may be affected ; in some cases the entire twenty are similarly 
involved. The conditions of hypertrophy, atrophy, and dystrophy of 
the nails are frequently present in a single case, and it is often difficult 
to say which process is the most prominent. 

In the rare cases of congenital nail hypertrophy there is often a dis- 
tinct hereditary tendency to the same disorder, and in many cases a 
coincident atrophy of the hairs and dental malformation. In one of 
our patients the teeth were wholly lacking and the hairs on the scalp 
were rudimentary. 

The diseases in which these changes occur as symptomatic lesions 
are numerous, since it is evident that the matrix, from which the nail 
is produced, does not enjoy immunity in the case of profound altera- 
tion of the skin in its vicinage. Thus, eczema, lepra, acromegaly, 

1 For full discussion of diseases of the nails, see monograph by Heller, Die Krank- 
heiten der Nagel, Berlin, 1900 (complete bibliography). Also papers of Grindon, 
Pollitzer, Zeisler, and Hardaway (with discussion), Trans. Anier. Derm. Assoc, 1901, 
pp. 111-144, and Jour. Cutan. Dis., 1901, xix., pp. 503-538. 



PLATE XIII. 







Syphilis of the Nails. 



ONYCHAUXIS. 535 

psoriasis, lichen ruber, syphilis, scarlatina, perforating disease of the 
foot, variola, and other diseases are attended by changes of various 
grades of severity in both matrix and nail. Among the important 
affections in this list is the trophic change often found in the feet, but 
also in the hands, where circulatory changes (often associated with 
cardiac disease) play an important part. In these cases the dystrophy 
of the nail-substance may be associated with dysidrosis, palmar or 
plantar keratosis, hyperidrosis, and hypertrichosis of the lower arm 
and the leg. 

In the condition termed Paronychia (Whitlow) one or both 
lateral borders of the naii bury themselves deeply in the tissues adja- 
cent, producing thus an exquisitely tender and painful state of the 
soft parts, which may suppurate or surround the attached flange of the 
nail with exuberant granulations. This condition is more frequently 
observed in the nails of the toes, as these appendages of the skin of the 
feet are liable to injury from the pressure of ill-fitting boots, gaiters, 
or shoes. In the condition described as Onychia the matrix is not 
only inflamed, but the nail-substance is, as a consequence, texturally 
changed. No strict line of demarcation, however, can be described 
between the two conditions. The term Onychogryphosis has been 
employed to describe the contorted deformities which cause the nail to 
resemble a claw. 

Onychomycosis is the name given to that condition in which the 
nail-substance is invaded by vegetable parasites. In such cases the 
nails become opaque, discolored, and thickened, with a noticeable fria- 
bility at the projecting border. 

Syphilitic Onychia is the condition in which one or several of 
the nails may become affected, though it is quite characteristic of the 
disease to exhibit limitation to the extremity of a single digit. In 
such a case there is usually a marked involvement of the peripheral soft 
parts, which may be infiltrated with gummatous material, though the 
nails may be extensively damaged when the soft parts of the fingers are 
apparently normal. The bullous syphiloderm, among the congenital 
manifestations of the disease, will at times form beneath or quite near 
the nail, thus endangering its integrity. In both forms ulcerative 
results are common, with secretion of a foul discharge. 

In the affection termed " perforating disease of the foot " all the 
nails of the organ affected may exhibit a characteristic onychauxis or 
dystrophy. 

Traumatism (constant or intermittent pressure of shoes) may aug- 
ment the size of the nail in one or another diameter ; and the deformed 
talons resulting from gross and long-continued neglect (East Indian 
devotees, etc.) are illustrations of another type of hyperplasia. Super- 
numerary nails may be found on supernumerary fingers and toes ; or 
double organs on a single digit ; or in unusual situations, as over the 
scapula (Tulpius) ; or on a digital stump ; or in an ovarian cyst. 

Scleronychia (Unna 1 ) is characterized by a persistent develop- 
ment of dense, inelastic and roughened, often discolored nails, yellow- 
1 Histopathology, p. 1051 (Eng. trans.). 



536 HYPERTROPHIES. 

ish-gray in hue, in which the lunule disappears, and the surface is 
roughened, mammillated and otherwise changed. The nails of all 
the fingers and of the toes may be involved 

With respect to onychauxis proper, two forms are recognized : in 
the first, the nail-cells are more closely set together and the resulting 
hypertrophy is declared, not in changes in bulk of the nail, but in a 
dense, thick, opaque, glossy, grayish-white transformation of the organ. 
The nail is perceptibly increased in weight and becomes so solid that it 
cannot be cut with ordinary implements. It may be also, though not 
changed in bulk, altered in shape, its free border being curved down- 
ward or upward. 

The second form represents a visible hypertrophy in bulk, the nail 
being enlarged in one or several diameters. Enlargement in a trans- 
verse diameter necessarily involves the soft parts adjoining. Vertical 
hypertrophy results in any one of the claw- or talon-like forms of 
onychogryphosis. 

Etiology. — Onychauxis may be congenital or acquired, idiopathic 
or symptomatic. A long list of disorders of the general economy, in- 
cluding lepra, syphilis, gout, and tuberculosis, may be responsible for 
changes in the nail. Onychauxis also may be due to inflammatory 
changes in the corium or matrix of the nail ; to almost all the cuta- 
neous affections of inflammatory type ; to improper covering of the 
feet ; to traumatism ; to defective hygienic care of the general surface 
of the skin, including the nails ; and in exceptional cases to senile 
influences. 

Treatment. — The treatment of the disorders of the nails described 
above is largely that of the maladies in which they occur. Arsenic 
and iron are often indicated in these affections, and their influence upon 
the nutrition of the nail cannot be questioned. In syphilitic onychia 
the constitutional treatment of the disease is essential. The cutting, 
scraping, and trimming of the nail with the aid of the useful instru- 
ments found in the case of the manicure and the chiropodist are 
important measures in many patients. 

The treatment of ingrowing toenail varies with the extent of the 
disease. In mild cases soft threads of charpie are insinuated between 
the offending border of the nail and the tender surface upon which it 
presses. Counter-pressure by plaster and the local use of a crayon 
of silver nitrate may be at times employed with advantage. In severe 
cases the nail may be removed, though this is generally unwise. The 
soft parts are, by some surgeons, completely removed from the side of 
the nail by means of a thin-bladed bistoury, and the nail permitted to 
grow down upon one side of the extremity of the distal phalanx, thus 
protecting the cicatrix and radically preventing recurrence of the 
disease. 

The management of onychia and paronychia may demand soaking 
in hot alkaline or borated aqueous solutions, the application of caustic 
in stick or solution to exuberant granulations, and the subsequent 
wrapping of the digit, the nail of which is affected, with salicylated or 
mercurial salves. 



HYPER TRICHOSIS. 



537 



The proper dressing of the feet in onychauxis of the toes is a matter 
of great importance. The shoes and socks or stockings should be ad- 
justed both as to texture and shape to the special requirements of each 
case. After the hypertrophied tissue is removed, largely by cutting or 
scraping, the phalanx may be enveloped in a plaster-mull or salve- 
muslin of diachylon ointment, or with mercurial plaster, and the whole 
be covered with a leather cot. The use of rubber cots and gloves is to 
be discouraged, as these have a distinct tendency to destroy the nail- 
substance. 

The Prognosis in disorders of the nails rests entirely upon the 
nature of the malady in which they occur. Idiopathic and localized 
changes, as also those occurring in transient cutaneous diseases (e. g., 
the exanthemata), often terminate favorably. In severe constitutional 
or grave cutaneous diseases the outlook is less promising. The diseases 
of the nail are usually more obstinate and less amenable to treatment 
than the similar affections of the softer parts. In cases in which there 
is congenital disease of the nails a prognosis should be made with 
reserve. 

HYPERTRICHOSIS. 

(Gr., vnep, in excess; dpi^ hair.) 

(Hypertrophy of the Hair, Superfluous Hair, Hairiness, 
Hirsuties, Hypertrichosis, Polytrichia, Trichauxis. 
fr.. poils accidentels. 



In the condition of hairiness the pilary filaments may be increased 
in number or size, or be developed abnormally with respect to the 
region or age of the person who is 



Fig. 58. 



the subject of the anomaly. 

Symptoms. — Hypertrichosis 
may be congenital or acquired, 
and partial or universal. In con- 
genital hairiness it is common to 
see infants at birth with extremely 
long hairs on the hairy part of 
the body, this growth being usu- 
ally replaced later by shorter fila- 
ments. Partial congenital hir- 
suties is illustrated in pigmentary 
nsevi. Universal congenital hir- 
suties is a rare deformity, the 
entire body then being covered 
with longer or shorter downy 
hairs of various colors. 

Remarkable instances of uni- 
versal congenital hirsuties are 
observed occasionally. The so- 
called " Russian dog-faced man " (Andrian Jeftichjew) and his son 
were noteworthy illustrations of this anomaly. In most cases the in- 
fluence of heredity is distinct and often is accompanied by defective 




The Russian "Dog-faced Man. 



538 HYPERTROPHIES. 

dental development, such as entire absence of molar or of canine teeth. 
This anomaly may be exhibited in generations of one family. 

Acquired hirsuties may be partial or universal, much more com- 
monly the former. Thus, the hairs of the scalp or the beard may 
acquire an enormous vigor and length, reaching to the ground when 
the body is in the erect position ; or the hypertrophy of the hairs may 
affect the face of the child or the woman ; and in persons of the sex 
last named either the upper lip, chin, cheeks, or all portions of the 
body usually covered by hairs in man, may be provided with a 
vigorously and symmetrically developed pilary growth. 

In all cases of hypertrichosis, whether congenital or acquired, the 
parts normally unprovided with hair are not the seat of the pilosis. 
The hairy regions in these cases may be provided with a few or many 
follicles, each of which is the seat of two, three, or even more filaments. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so the hypertrichosis of women and 
children is at times related to a precocious, perverted, or arrested func- 
tion of the generative organs. The reported instances of menstruation 
in female infants and children usually include a description of abnormal 
pilary development about prematurely developed pudenda; and after 
the climacteric period, when some women conspicuously in external 
appearance begin to resemble individuals of the opposite sex, either 
isolated, thick, bristle-like hairs develop over the chin or lips, or the 
extreme hirsute condition may be reached. Duhring 1 reported one 
such case, which is illustrated by a lithograph representing the face of 
a woman provided with a superb beard. 

The influence of the sexual organs in the hypertrichosis of women is 
well demonstrated in the following case coming under our observation : 

A married woman, thirty-three years of age, weighing one hundred 
and fifty pounds, mother of three healthy children, applied for relief 
of a general and facial hirsuties which had resulted in the growth of a 
full beard and moustache. She had not menstruated for more than a 
year, and had been pronounced by an expert to be past the climacteric. 
During 1884 and 1885 the hairs of the face were removed in succes- 
sive operations by the electrolytic method described below. Menstrua- 
tion began while she was subject to the influence of the galvanic cur- 
rent in the operating-chair, and continued thereafter irregularly, at 
times with intense pain and even menorrhagia. In 1886, after the last 
of the operations on the face, she rather suddenly lost in weight, 
decreasing to one hundred pounds, and began to menstruate regularly 
and painlessly. The hypertrichosis of the general surface then spon- 
taneously disappeared. In the latter part of the year she again con- 
ceived, and in March, 1887, being then free from hirsuties, she 
brought a healthy male child into the world. 

As the result of the persistent application of stimulating and oily 
liniments over a region of the body (scapula, sacrum, sciatic notch, etc.), 
as also after traumatism by pressure or otherwise, a growth of long and 
numerous hairs is often produced. Care should be had in the manage- 
ment of cases of acne and rosacea in the persons of dark-skinned 
1 Arch, of Derm., 1877, iii., p. 193. 



HYPERTRICHOSIS. 539 

young women with luxuriant hair upon the head, lest a similar growth 
be produced upon the chin, cheeks, or nose. 

In cases of hypertrichosis the hairs may be colored variously, and 
the hypertrophy of downy hairs purely be numerical, or result in 
increase in the actual size of the shaft of the individual filaments. In 
neither case do the hairs present any anatomical peculiarities of struc- 
ture. The localized congenital form of hirsuties is often characteristic 
of certain moles, known as N^vi Pilosi. The surface of pigmentary 
moles (Njevi Pigmentosa) is often very extensively covered with hairs 
of a dark color. Singular anomalies have been figured in which exten- 
sive regions (one or several limbs, the entire back, even the greater 
part of the body) were the seat of enormous pigmented moles, covered 
with warts, fibromata, and other benign tumors, and clothed with a 
thick covering of longer or shorter hairs. 1 All such cases exhibit a 
striking development in either symmetrically or asymmetrically dis- 
posed areas of distribution of cutaneous nerves. 

The Hypertrichosis Neurotica of authors is that condition in 
which an excessive growth of hair has succeeded spinal paralysis and 
other morbid conditions of the nervous centres. Under the title Tro- 
phoneuroses of the Skin in this work are described changes of a similar 
kind, in which there is association of hypertrichosis with hyperidrosis, 
changes in the nails, and even extensive tylosis of the palms and soles. 

Plica Polonica was formerly supposed to be a disease peculiar to 
Poles (whence its name), but which has long been recognized as a re- 
sult merely of persistent neglect, filth, the invasion by parasites, and 
consequent exudative disorders of the scalp. When it exists the hairs 
form a huge matted mass on the crown of the head. Hebra devotes an 
interesting chapter to the superstitious awe with which this accumula- 
tion of hairs, lice, and filth has been regarded. In Alaska a number 
of cases of plica have been observed among the natives of that region. 
A typical case of this deformity was lately presented at our clinic. 

Neuropathic Plica. — Le Page 2 described a case in which tangled 
" lumps " and " festoons " of hairs, flat, curled, looped, and inter- 
twined appeared on one side of the head of a girl seventeen years old, 
who had previously suffered from neuralgic pains in the site of the 
growth. Similar cases have been reported by Stelwagon 3 and others. 

Trichiasis is that condition in which the eyelashes, diverted from 
the normal line of projection, are turned inward so as to irritate or 
wound the conjunctival membrane. In Distichiasis a double row of 
filaments can be recognized, which are liable to induce similar ocular 
distress. 

Etiology. — The causes of hypertrichosis are obscure. Whatever 
determines the blood in excess to any region of the body supplied 
with hair-follicles indirectly may be the cause of hypertrophy of 
hair, a fact demonstrated in patients who, after applying sinapisms 

1 See the authors' case of nsevus lipomatodes in a child, the pilary growth being at 
that age undeveloped. Jour. Cutan. Dis., 1885, iii., p. 193. 

2 Brit. Med. Jour., 1884, i., p. 160. 

3 Diseases of the Skin, p. 884 (bibliography). 



540 HYPERTROPHIES. 

or liniments for years to the skin over the seat of a rebellious neuralgia, 
exhibit in this region an abundant growth of hair, often several inches 
in length. In women, whose sex renders the anomaly most deforming 
and distressing, it is noted, as has been observed, in precocious, per- 
verted, or arrested activity of the sexual function. It may be a racial 
peculiarity, a family trait, an inherited anomaly, or an epiphenomenon 
in dwarfs, monsters, individuals atfected with club-foot, insanity, and 
congenital deformities of several kinds. The neurotic conditions 
accompanying certain varieties of hirsuties may be inappreciable ; or 
evidently be due to traumatism ; or be exhibited in paralyses, muscular 
atrophy, etc. 

Treatment. — To Hardaway, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs by 
electrolysis, first devised by Michel, of his city. Extensive pilary 
growths are now often removed by this method without subsequent 
reproduction of the hairs. A fine needle is introduced into the hair- 
follicle and gently passed down to the papilla at its base. This instru- 
ment is connected with the negative pole of a galvanic battery contain- 
ing six or more elements, the positive pole of which is in connection 
with a sponge-electrode held in the patient's hand, who is thus enabled 
to make or break the circuit at will. When the current is passed a 
few minute bubbles of gas escape from the orifice of the follicle, and 
when the hair-papilla is destroyed the hair itself is readily extracted. 
The dexterity acquired by practice is requisite for the proper perform- 
ance of the operation, with a view particularly to the insertion of the 
needle at the proper angle into the follicle. Few patients complain of 
pain. The number of hairs removed at a sitting varies with the sensi- 
tiveness of the patient's skin. The resulting scar is quite imperceptible 
or far less disfiguring than the hirsuties, suggesting the appearance of 
the male beard after shaving. Transitory macules, papules, pustules, 
and wheals occur at the site of puncture. Care should be taken not to 
insert the needle too deeply in the particularly vascular regions of the 
face, as an aneurysmal tumor might be produced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as confirmed 
by our experience, may be given as follows : 

1. Any good galvanic battery may be employed. We use habitu- 
ally a forty-cell stationary battery, the switchboard of which is so 
arranged that any number of selected cells may be brought into the 
circuit. A galvanometer should be placed in the circuit indicating a 
current of from one-half to four milliamperes. The number of cells 
employed should vary with different individuals, different parts of the 
face, and on different days with the same individual — e. g., a smaller 
number is required when a patient previously operated upon returns 
after a somewhat long period of rest. Two to four cells only may be 
tolerated over the tip of the nose or the upper lip near the septum nasi. 
Twelve to twenty may be well borne, after some experimenting, on an 
insensitive chin. 

2. The best needle is a carefully selected, fine jeweller's broach, its 
shaft and point being annealed by rapid passage through the flame of 



HYPERTRICHOSIS. 541 

an alcohol lamp. It is often useful to have the point also well rounded 
on an emery-wheel. Irido-platinum needles are useful, but inferior 
for general work to a broach. 

3. The needle-holder should be simply a convenient insulated 
handle, sufficiently long to protect all the points of the operator's right 
hand from the current, and should be as light as possible, since a 
heavy holder interferes with delicacy of touch. Duhring's 1 holder, 
which is of the shape of a thin lead-pencil or pen-holder, is about four 
inches in length. The handle, or stem, is of hard rubber, through 
which passes a metallic rod, acting as a conductor for transmission 
of the current. The needle is inserted into the needle-holder proper, 
which is slotted, the needle being clamped immovably by means of a 
screw-nut. In the other end of the stem is an insulated inserting-pin 
attached to the cord leading to the battery. The instrument is con- 
venient to handle and altogether well adapted to the operation. 

4. The patient should be seated or reclining at ease in a good light, 
with the handle of the electrode connected with the positive pole of the 
battery in one hand, ready to press the sponge into the palm of the 
other. In this way, at the bidding of the operator, the patient makes 
and breaks the circuit at will. The sponge attached to the holder 
should be wet with a solution of salt and water. 

5. As to further details of the operation, it is well (a) to make and 
break the connection only when the needle is in situ, as this diminishes 
the pain of the operation ; (6) to introduce the needle with a gentle ma- 
nipulation (acquired only by skill and well characterized by Hard- 
away as a " catheterization " of the hair-follicle), observing a certain 
degree of parallelism with the hair-shaft as the needle enters ; (c) to 
operate leisurely, making sure that the current is not broken by sep- 
aration of the hands of the patient before the hair is completely free 
in the follicle. This last can be ascertained by gentle traction on the 
shaft in from twenty to forty seconds after insertion of the needle ; 
(d) to operate in succession upon contiguous hairs when practicable, not 
selecting one here and one there, the latter course being productive of 
greater pain ; (e) never to use the positive pole in connection with the 
needle, an error which results in the production of unsightly pigmented 
blemishes on the surface of the skin. 

The previous employment of preparations of cocaine both hypoder- 
matically and by inunction — e. g., cocaine oleate — to relieve or diminish 
the pain of the operation, may be followed by exceedingly unpleasant 
consequences. A dermatitis thus induced may persist for months. 

Prince, of Boston, 2 lays stress upon the accurate regulation of the 
current by the aid of the absolute galvanometer, which we have found 
in practice useful but not essential. Fox, 3 of New York, reports a 
gradual decrease in the number of hairs returning after operation, 
proportioned to the improvement in the instruments and the skill 
of the operator. The percentage of such returns varies with these 
conditions. 

1 Amer. Jour. Med. Sci., 1881, Ixxxii., p. 142. 

2 The Exact Measurement of the Electric Current, and other Practical Points in 
the Destruction of Hair by Electrolysis. 

a The Use of Electricity in the Kernoval of Superfluous Hair, etc., Detroit, 1886. 



542 HYPERTROPHIES. 

All patients affected with hirsuties are not to be advised the opera- 
tion. We have declined to operate in many cases which were not 
deemed to belong to the class in which the best results of the operation 
may be expected. Young and vigorous women, usually unmarried, 
may point out hairs to be removed that are merely full-developed fila- 
ments of a thick downy growth, all the hairs of which are rapidly 
pushing to equal maturity. Here the operation itself, by inducing 
hyperemia of the skin, may simply hasten the hypertrichosis actually 
in progress, and thus aggravate the disorder. In most cases, when an 
operation is undertaken, both parties should fully understand the possi- 
ble issue. It is a question whether it lies within the legitimate sphere 
of the physician to remove superfluous hairs from the habitually covered 
breasts and arms of women. 

This operation has unfortunately found its way into the hands of 
the unprincipled and the ignorant, who, in their efforts to extract 
money from the credulous, have in some of the larger cities brought 
electrolysis for hypertrichosis into ill repute. The operation is, how- 
ever, all that can be desired if only it be performed with sufficient 
skill and conscientiousness ; but if hairs are rapidly plucked away from 
their follicles while an electric current is passing merely, the return 
of each filament is prompt and mortifying to the patient. It should, 
therefore, be understood as a procedure requiring ample time on the 
part of the operator, and either fairly good vision or eyes aided by a 
mounted lens. Not more than from forty to sixty hairs can be re- 
moved in an hour by an expert operator ; and there are few who can 
work with advantage more than one hour at a sitting, or more than one 
or at most two hours in a day. 

Hairy nsevi may be removed by complete excision, but removal of 
the hairs by electrolysis will sometimes result in disappearance of the 
entire growth without such operation. 

In 1897 Freund 1 reported that he had succeeded in removing the 
hairs from a large hairy nsevus by using the x-rays. The method was 
developed further by Schiff and Freund, 2 and has been employed since 
by many observers, including Benedikt, Ehrmann, Jutassy, Pusey, 3 
and ourselves. 

There are few cases in which the hair cannot be removed temporarily 
by the use of the x-rays, but it returns after periods varying from six 
weeks to six months. When the hair falls as a result of a few expos- 
ures given during a brief period of time, the growth usually returns 
in its normal vigor, and in some instances the new hair has appeared 
to be stronger and more abundant than the original. In cases which 
have received from fifteen to forty treatments with the production of a 
mild erythema, the number and strength of the returning hairs may be 
diminished considerably. This second growth can frequently be re- 
moved with a smaller number of exposures than was required to 
remove the hair the first time. 

1 Wien. med. Wchnschrft., 1897, xlvii., p. 428. 

2 Ibid., 1898, xlviii., p. 1058. 

3 Pusey-Caldwell, The Koentgen Rays in Therapeutics and Diagnosis, Philadelphia, 
1903, p. 339 (with bibliography). 



HYPERTRICHOSIS. 543 

In the majority of all cases treated with the x-rays successive re- 
movals of the growth are followed by the return of a steadily dimin- 
ishing number of hairs, and in some instances an alopecia has been 
produced which has persisted a year or more. More frequently a 
small number of hairs continue to return, and in order to keep the 
surface epilated a few treatments must be given every two to six 
months. 

Of fourteen cases treated by us, four apparently are successful in that 
the hairs have not returned during a period of one year, o^ have 
returned in such small numbers that a few treatments keep the face 
clear. In three of these four cases the growth was extensive and 
strong. The total number of treatments required in each instance 
varied from forty-four to one hundred and sixteen. In six individuals 
the treatment has lessened the hypertrichosis decidedly, but has not 
removed all the hairs permanently. 

As any treatment of hypertrichosis is employed solely for cosmetic 
purposes, it is necessary to employ mild exposures only, and to take no 
chances of producing a dermatitis. On the other hand, permanent 
results can rarely be obtained without pushing the treatment to the 
point of producing some erythema or pigmentation, and repeated mild 
exposures may stimulate slightly the growth of hair. As individuals 
vary considerably in the readiness with which their tissues respond to 
the action of the rays, it follows that the treatment of hypertrichosis 
by radiotherapy is a procedure that calls for a delicate adjustment of 
the method to each case. 

Short and mild exposures repeated, and, if necessary, increased in 
strength until the desired effect is produced, are far safer than efforts 
to hurry the treatment. For hairy nsevi and for small areas of hyper- 
trichosis, or when the hairs are not numerous, electrolysis undoubt- 
edly gives equally prompt and better results, and radiotherapy should 
be reserved for the more extensive cases. 

Following the removal of the hairs with the x-rays there is left often 
a slight atrophy or wrinkling of the skin. In most instances this 
result is so slight as to be inconspicuous, but we have seen several 
cases, and others have been reported, in which too vigorous or too fre- 
quent treatments have produced an atrophy of the skin as disfiguring 
as the original hypertrichosis. In two instances in which we had 
employed electrolysis for a part of the growth, eleven and twenty-nine 
exposures, respectively, to the x-rays caused the hairs to fall, but they 
promptly returned as numerous and as vigorous as before. On resum- 
ing the treatment by electrolysis, however, we found in both instances 
that the mouths of the follicles were distinctly narrower, and that it 
was much more difficult than before to introduce the needle into the 
follicle, showing that some atrophy of the structures had taken place. 
Bronson l reports a similar experience. 

Depilatories for the removal of superfluous hairs operate by the de- 
struction of the filament without obliteration of the papilla. The con- 
sequence is that the hairs are reproduced in the course of about a fort- 
night. Most of the compounds used for this purpose contain either 
1 Personal communication. 



544 HYPERTROPHIES. 

calcium sulphate, arsenic sulphate, or barium sulphide, made into a 
paste with warm water. This paste is applied over the hairy surface 
with a spatula, and is permitted to remain until it dries, or produces a 
sensation of heat or burning, a period usually requiring ten minutes. 
It is then rapidly removed by scraping with a spatula, and the surface 
thoroughly cleansed with warm water, after which the skin is anointed 
with cold-cream salve or other similar unguent. 

Of these depilatories Duhring recommends the following : 

R Barii sulphidi, 3ij ; 8 

Pulv. oxid. zinc.,) -_ _... -- -.o 

Pulv.amyl., } aa Su * > aa 12 M. 

To be prepared in form of an impalpable powder, which, just before 
using, is to be mixed with water to form a thin paste. 

The following are formulas devised by French authors : 

R Sodii hydrosulphit, 3iij ; 12 

Calcis, 1 -- _ -- Aa 

Amyli pulv., J aa Z *> aa 40 M. 

To be finely triturated, and, when used, to be made in a thin paste 
with water. (Boudet.) 



R Calcis, 3j ; 4 

Sodii carbon. , 3jss ; 6 

Cerat. adipis, ^j ; 30 

To be applied as a depilatory in the manner of a paste. 



M. 



All these formulas require caution in their use, and they should 
rarely be intrusted to patients themselves. 

Shaving may be practised upon the hirsute face of women, and, 
with a similar end in view, also epilation ; the latter, particularly in 
cases of hypertrophy of the hair limited in extent. Partial success 
has attended the thrusting into the follicles of needles previously 
dipped in caustic solutions, or heated in various degrees, but these 
methods are inferior to electrolytic destruction of the hair-papillse. 
The hairs may be rendered less conspicuous by bleaching them with 
frequent applications of hydrogen peroxide. Bulkley 1 states that a 
thorough use of this remedy retards the growth of fine hairs. 

(EDEMA NEONATORUM. 2 

CEdema of the newborn is characterized by the occurrence of an 
indurated tumefaction of the skin, most noticeable in the lower ex- 
tremities of infants affected with impaired circulation. 

CEdema and sclerema of the newborn have long been confused. The 
distinction between them was first well established in 1877, when Par- 
rot, under the title Athrepsie, first described with clearness the 
morbid condition now recognized as oedema neonatorum. 

1 Jour. Amer. Med. Assoc, 1899, xxxiii., p. 1598. 

2 Full bibliography for oedema neonatorum and sclerema neonatorum is given by 
Soltmann in Eulenburg's Real-Encyclopadie, 1899. 



(EDEMA NEONATORUM. 545 

Symptoms. — The disease, which is of exceedingly rare occurrence 
in America, is observed in infants prematurely brought into the world 
or at term, and of feeble vitality. Between the first and the third day 
after birth the child is found to be drowsy and difficult to waken, with 
the posterior and other parts of the thighs and legs, the hands, and 
the genital organs pallid, cold, livid, and retaining the impress of the 
finger as do cedematous tissues in general. At this point recovery may 
ensue, but in severe cases the oedema spreads, always more markedly in 
the lower portions of the body, and the skin becomes violaceous red, deep 
yellowish, or dirty looking. As the disease advances the integument 
becomes more and more difficult of indentation. Meanwhile the little 
patient becomes more drowsy, its respirations fewer, its cry weaker, 
and its temperature lower. Death may ensue from a pulmonary com- 
plication, from diarrhoea, or from any intercurrent disorder. Usually 
the child passes into a state of coma. When recovery ensues the oedema 
becomes less marked and the indurated skin more and more impressi- 
ble. A few days, in satisfactorily managed cases, suffice to restore the 
patient to a condition of health. In some instances the oedema begins 
in other portions of the body than those named ; and in cases there is a 
marked febrile reaction. 

Etiology. — The recognized causes of the malady are prematurity 
of delivery, cardiac feebleness, syphilis, exposure to severe cold soon 
after birth, poor hygiene, atelectasis of the lungs, and malnutrition 
from inability to take the nipple. Blacker, 1 describes a case, seem- 
ingly typical, in which there was no evident etiology. The child at 
five weeks was perfectly well and properly nourished, but still re- 
tained the hard oedema of the buttocks, thighs, part of the arms, and 
chest. The mother was always well, and the pregnancy, labor, and 
puerperiurn presented no unusual features. 

Pathology. — All cases show an effusion of yellow serum into the 
subcutaneous tissue, possibly in consequence of the enfeebled action of 
the heart, and the fat on excision is found to be particularly dense 
and yellowish. Enlarged liver, pulmonary congestion, venous throm- 
bosis, and nephritis have been recognized in a small number of cases. 

Diagnosis. — The distinction between oedema and sclerema neona- 
torum is not made without difficulty, the disorders greatly resembling 
each other. In sclerema the joints, and particularly the jaws, are 
immobile ; the disease is likely to be generalized ; the induration of the 
integument is greater ; and there is no tendency to an oedema chiefly 
marked in dependent parts of the body, as over the lower limbs. 
The color of the skin in the two disorders may be nearly the same. 
The pitting on pressure of the swollen skin is highly characteristic of 
oedema neonatorum. Scleroderma does not occur in children before 
the close of the first year. 

The Prognosis is grave, nearly 90 per cent, of the affected perish ; 
but with proper treatment recovery may occur when the oedema is not 
generalized. 

The Treatment is that of scleroderma neonatorum. 

1 Brit. Jour. Derm., 1898, x., p. 87. 
35 



546 HYPERTROPHIES. 

SCLEREMA NEONATORUM. 1 

(Gr. GK^vpoc, hard; veov, new; yevvdo), to bring forth.) 

(Scleroderma Neonatorum; Sclerema of the Newborn. 
Ft., Sclereme des Nouveau-nes; Athrepsie. Ger., Fett- 

SKLEREM.) 

This disease is not to be confused with oedema neonatorum, from 
which it is distinct. It was described first by Underwood in 1784/ 
and is an affection of extreme rarity. 

Symptoms. — At birth, or between the second and the tenth day 
after, the lower limbs of the child assume a livid or whitish-yellow 
appearance, occasionally suggesting the hue of wax ; and they become 
of a leathery consistency. This condition spreads gradually over the 
lumbar region, the dorsum of the body, and the chest in front and 
behind, and in the course of a few days may involve the entire in- 
tegument. When pressed upon with the finger the skin produces the 
impression of half-frozen tissue ; the face suggests a cold and rigid 
mask ; the thighs in their sockets and the arms in the shoulder-joints 
are immobile. Usually there is somewhat less firmness of the abdom- 
inal integument. The taking of the nipple, deglutition, and even the 
opening of the oral orifice are effected only with great difficulty, 
and eventually become impossible. The respirations are shallow and 
imperceptible ; the pulse in well-marked cases is imperceptible at the 
wrist ; and the thermometer in the rectum is not raised to the lowest 
register of the ordinary clinical instrument. There is often no cry. 

There may be a coincident icterus ; and often sprue has been observed 
in the mouth before the declaration of well-marked symptoms. The 
congenital patients are often stillborn. The majority of subjects of the 
disease perish before the ninth day. 

Etiology. — The immediate cause of the malady is retardation of the 
circulation in the cutaneous capillaries, and this may depend upon prior 
disease (pleuro-pneumonia, intestinal disorders) or upon conditions oper- 
ating before or at birth (congenital anomalies of lymphatics, syphilis, 
feeble vitality). 

Pathology. — Ballantyne has observed a small-cell growth in the 
corium, of perivascular situation ; Langer ascribes the condition to ex- 
cess of fatty acids in infants as compared with adults, with the result of 
producing a fat consolidation. In Northrop's cases 3 no fluid escaped 
on section of the tissues, which were as semisolid as if frozen ; scattered 
hemorrhages involved the alveoli, connective tissue, and lymph-spaces 
of the lungs, but there was no collapse. According to Ballantyne, the 
disease is due to overgrowth of connective tissue leading to atrophy of 
the fat-cells and is dependent upon a trophoneurosis. Parrot recognized 

1 For full discussion of the subject and bibliography, see monograph by Luithlen, Die 
Zellgewebsverhartungen der Neugeborenen, Vienna, 1902 ; also Mracek's Handbuch, 
vol. iii., p. 193. 

2 Diseases of Children, 1784, p. 76. 

3 Arch, of Psediat., 1890, vii. 



SCLERODERMA. 547 

the fact that the connective-tissue trabecular were more numerous and 
thicker than in other cases. 

The Treatment of both oedema and sclerema neonatorum is by ele- 
vating the body-temperature (in an incubator, wrapping the entire body 
in wool, warm water-baths, etc.), and by improving the nutrition in 
every possible way (sterilized milk and stimulants by the stomach- 
pump, through nose or pharynx). The body may also be well rubbed 
with warmed oil or camphorated alcohol. Brocq suggests friction with 
the warm hand from below upward. 

The Prognosis is grave ; in rare instances when the sclerema has 
been partial, recovery has ensued. 

SCLERODERMA. 1 

(Gr. OK~Ar)p6Q, hard; depfia, the skin.) 

(Hide-bound Skin, Dermatosclerosis, Chorionitis, Scleriasis, 
Sclerema Adultorum. Ger. Hautsclerem ; Fr., Sclero- 

DERMIE.) 

Scleroderma is a condition in which the skin is affected with a cir- 
cumscribed or symmetrical, variously tinted induration, exhibited at 
times in spots, streaks, bands, or patches, often associated with telangi- 
ectases of the part involved. 

There are two fairly distinct variations of the process, the sym- 
metrical and the circumscribed — the two in rare instances merging. 

Symptoms. — [A] Diffuse Symmetrical Scleroderma. — The skin- 
symptoms of the disease may slowly or rapidly be evolved, and pre- 
ceded by prodromic pains of a rheumatismal character, or by singular 
cutaneous sensations (pricking, tingling, formication), or by muscular 
cramps, and neurotic sensations. In some instances, also, there are 
vesicles, blebs, scales, local hyperidroses, or losses of sensibility in the 
skin which is about to become the seat of the disorder. 

With and without these prodromic features the skin and subcutane- 
ous tissue, chiefly of the upper portion of the body, become symmet- 
rically involved either in a gradually increasing induration or in an 
obscurely defined oedema of a firm character which at first pits under 
strong pressure with the finger, but later becomes as indurated and tense 
as hard leather. The integument is usually exceedingly difficult to 
pick up between the finger and thumb, and is shining, smooth, waxy, 
or of alabaster-like hue ; in other cases it is of a dirty -yellowish, grayish 
shade. The line of demarcation between the sound and the affected 
integument is indistinct. The onset of the disorder may be acute, 
rapidly involving the body-surface, or the sclerodermatous change may 
be insidious in its progress, affecting one region only and thence slowly 
spreading to others, or being arrested after any grade of advance has been 
attained. This is the stage of infiltration, and w T hen pronounced, it is not 
to be mistaken for any other condition. The face may be, both to the 
eye and the finger, mask-like, immobile in features, and expressionless, 
1 For complete bibliography, see Linthlen, Mracek's Handbuch, iii., p. 128. 



548 



HY PERTH OPHIES. 



The lips are then stiffened and opened with difficulty ; the eyelids are 
similarly but much less severely involved. The back of the neck may 
be firm; the chest, shoulders, and arms may be either immobile or 
movable with difficulty ; the ribs are often bound down so firmly by 
the cuirass of leathery integument that respiration may be impeded 
seriously. The temperature is not changed, and sweat may or may not 
be exuded over the affected areas. The abdominal surface is relatively 
spared. This condition may come on insidiously, and may require 
years for its complete evolution ; at other times the progress is rapid 
and the evolution is even subacute in type. Often the upper extremities 
are so involved that the fingers resemble curved talons ; the wrists lose 
their flexibility, the forearms their usefulness. So extreme is the help- 
lessness of some patients that they require to be dressed, washed, and 
fed, even when able to travel with relative comfort. 



Fig. 59. 
















Generalized scleroderma of long duration, with resulting ulcers. 

The lesions are accompanied at times by other subacute symptoms, 
such as subcutaneous tubercles, eczema, erysipelas, canities, anidrosis, 
zoster, and acne. The mucous membrane of the mouth and the vulva 
in women may be affected often without grave changes in the skin 
adjoining. 

In the later or atrophic stage of the affection the cedematous or 



> 

< 



a 



SCLERODERMA. 549 

infiltrated areas undergo induration and contracture. The skin becomes 
then more and more tightly stretched and thinned over the underlying 
structures, and it is no longer possible after drawing the finger over the 
surface to produce a yellowish-white tracing of its route that disappears 
as the circulation slowly returns along the line. When this condition is 
reached, the atrophic skin becomes dry, scaling, fissured, or even ulcer- 
ated ; the wrinkles of the face disappear ; the muscles waste consider- 
ably, thus reducing a limb several inches in circumference ; the teeth 
may fall ; the fingers permanently be flexed into the palm or the fore- 
arm on the arm. When the condition becomes to this extent grave, 
the patient, who before seemed to enjoy a fair degree of health, sud- 
denly experiences rheumatoid pains and neuralgias, or exhibits other 
signs of constitutional impairment ; and intercurrent visceral disorders 
gradually bring on a marasmus which in some of the reported cases has 
ended with renal, cardiac, or pulmonary symptoms. 

[B] Circumscribed Scleroderma; Morphcea (Gr. fiopcpy^ a blotch); 
Keloid (of Addison). — Circumscribed scleroderma, or morphcea, is 
characterized by the occurrence of one or of several discrete, well- 
defined, firm, and smooth points, patches, lines, or bands, that are often 
slightly elevated or depressed, and surrounded by a delicate violaceous 
or lilac-tinted halo, the involution of which may be followed by macular, 
punctate, or striate atrophy of the skin. 

This form of scleroderma was once held to be rare. It is, however, 
more commonly under observation than is usually believed. French 
authors distinguish between the variety displayed in plaques and that 
occurring in bands. Some forms of the latter variety are better 
described as linese atrophica?. 

Patches of morphcea commonly begin as rosy or violaceous mac- 
ules, which irregularly extend in area from nail-sized to larger patches, 
either with relative rapidity or with slowness. In a variable period of 
time the centre of each patch becomes whitish, while the peripheral por- 
tions of the plaque retain their peculiar shade of color. There is thus 
formed a roundish or oval or irregularly outlined area, rarely larger 
than a dinner-plate, with a central portion slightly deepened or some- 
what elevated, infiltrated and "lardaceous" or flattish, and near the 
level of the adjacent skin. The blanched centre has often the hue of 
old ivory ; later, this may be commingled irregularly with a flattened 
streak or band, distinguished with difficulty from scar-tissue. These 
patches may be single or multiple; in the latter event they are 
arranged, as a rule, along the line of distribution of the cutaneous 
nerves of the trunk, along the inner faces of the thigh, more often on 
the lower than over the upper extremities, and asymmetrical in most 
cases. When the tissue is pinched between the thumb and finger it at 
first gives the impression of stiffness and hardness ; in the later stages 
of the disease the skin may be so atrophied over the region involved 
that it is impossible to make this test. The surface is dry and smooth, 
or, when very carefully inspected, is seen to be traversed by exceed- 
ingly delicate lines. In some instances the plaque is dotted regularly 
with depressed points resembling the patulous orifices of sebaceous 
glands of the face in certain cases of acne, the slightly discolored, 



550 HYPERTROPHIES. 

minute, funnel-shaped orifices contrasting thus with the dead-white 
hue of the patch. In other cases this appearance of dotting or picking 
out of the surface is more conspicuous at one part than another, being, 
for example, well shown at an advancing border, with a dead -white, 
depressed centre, or at both extremities of a long oval. 

The border of typical patches is characteristic. It is made up usu- 
ally of a narrow zone having a pinkish, lilac-tinted, or violaceous hue, 
which, when closely viewed, is seen to be constituted of a plexus of 
fine vessels. The zone may be wanting wholly, as is well shown in 
some cases in which the temple is involved ; the border further may 
be present in such degree as to be fully as conspicuous as the whitish 
central area. In a patient presenting a palm-sized patch over the 
sacrum, together with a few multiple spots on the side of the neck (a 
portrait of the same having been made in oil), the flame-like, violet- 
shaded areola extended for several inches on one side away from the 
disk, and one of the larger vessels of which it was constituted could be 
seen at a distance of several feet from the patient. Purplish, and 
even blackish, hues have at times been recognized in the halo by other 
observers. 

As a rule, there are few subjective phenomena ; in some cases itch- 
ing, tingling, pricking, and other sensations are experienced. The 
variations observed in this affection are as numerous as they are strik- 
ing. In some cases the patches closely resemble scars ; in others there 
is marked pigmentation, diffuse or circumscribed ; in yet others the 
capillaries traversing the patch constitute a distinct network of pre- 
dominant symptoms ; in still other cases, usually of long continuance, 
the surface of an entire limb may be converted into tissue presenting a 
dull-reddish area in which new vessel-formation and sclerotic integu- 
ment are distributed equally. The disease may be extensive or be 
limited to one or a few very small spots. The names : Maculosa, 
Nigra, Lardacea, Alba, Plana, Atrophica, etc., are merely de- 
scriptive of clinical features, and are becoming obsolete. 

Between the several types of scleroderma noted above are to be 
found instances which it is difficult to assign to the one class or 
the other. Some are mixed forms in which diffuse scleroderma is de- 
veloped in one part of the body and a circumscribed form in another ; 
in other cases numerous morphoea plaques are distributed symmetrically 
over the body or develop a generalized symmetrical scleroderma. As 
a rule, the symmetrical forms occur most extensively over the upper 
part of the body ; while the more frequent unilateral plaques of mor- 
phoea affect in greater proportion the lower limbs. Often the symp- 
toms of the disease resemble at the outset those described as character- 
istic of oedema neonatorum, with pitting of an ©edematous surface under 
pressure. Great variation has been noted as regards the presence, 
absence, or increase of sensibility. Sweat and sebum may or may not 
be secreted from the affected patches. 

The course of the disease is usually chronic. Many patches after 
reaching an average degree of extension advance no further. In yet 
other cases the progress continues through life, or the serious phases of 
diffuse scleroderma in advanced grade are exhibited. 



SCLERODERMA. 551 

The sites of election of the disease are the face, the sides of the 
neck, the chest, the abdomen, and the extremities, though any region 
of the body-surface may be involved. Multiple patches may be dis- 
posed symmetrically or asymmetrically in different regions, and on dif- 
ferent sides of the body. 

In the generalized forms, whether symmetrical or not, there may 
occur serious complications from visceral disease (cardiac, vascular, or 
renal) due in part to interference with the function of large areas of 
the skin. Arthritis is not infrequently a concurrent disorder. In 
some cases the mucous surfaces are involved. In other cases there are 
organic changes in the viscera as well as sympathetic disturbances 
of function. Some of the visceral muscles have been recognized as 
involved in scleroderma. 

According to Besnier and Doyon, pigmentation is one of the most 
important of sclerodermatous symptoms. Beside the pigmented dots 
visible over the sclerosed patches, there often exists a species of chlo- 
asma in the form of bronzing, diffuse or in irregular islets, over the 
neck, shoulders, and elsewhere. These pigmentations are often inter- 
spersed with whitish patches of vitiligo. 

The course of circumscribed scleroderma is either chronic, lasting for 
from one to ten years or more ; or subacute, with evolution accomplished 
in a few days and an almost equally rapid involution ; or atrophy of 
skin, subcutaneous tissue, and muscle may slowly or rapidly follow, 
and result in the production of attachments to periosteum or in de- 
formity due to contracture. Ulceration may ensue, and in a few in- 
stances has occurred early in the disease. Atrophy of bone is an 
exceptional result. In yet other cases absorption of the material con- 
stituting the plaque is effected without sequels of any sort, few, if any, 
traces of the process remaining. 

The band-form of circumscribed scleroderma usually occurs in 
ribbon-shaped elongations stretching along a limb in its longitudinal 
axis, or over one-half of the face. Most of these cases are distin- 
guished by the occurrence of either an elevated ridge or furrow, or 
(what is not very rare) an elevated ridge with a furrow on one side. 
The median line of the forehead is the commoner site of this anomaly 
on the face ; over the trunk it is best displayed on the breast. As 
noted above, some of the cases collated in this category are instances 
of linese atrophica?. 

Finlayson l observed in one case of scleroderma symmetrical gan- 
grene of the extremities, a complication related doubtless to the " sym- 
metrical asphyxia of the extremities " described by a number of English 
authors. The so-called " glossy fingers " and " sclerodactylie " of 
symmetrical distribution may belong to the same category. 

Hemiatrophia Facialis. — Severe grades of the disease are noted 
by several authors, in which to a varying extent, the surface of the lateral 
half of the face has been involved. Here not only the subcutaneous 
tissue, but also the aponeuroses, periosteum, and bones may partici- 
pate in the atrophy, a fact well illustrated in the case of Robinson's 
patient. 2 In this instance there was also a distinct sclerodermatous 
lesion on the face of one thigh. 

1 Med. Chronicle, 1886. ' l Amer. Jour. Med. Sci., 1878, lxxvi., p. 437. 



552 HYPERTROPHIES. 

Etiology. — About three-fourths of all cases occur in women. The 
young and middle-aged are generally the victims of the disorder, though 
cases are reported between the first year of life and advanced age. 
The predisposing causes of the affection are : rheumatism and the 
climatic changes to which rheumatism is most often attributed; all 
neurotic states due to emotional influences, grief, anxiety, etc.; trau- 
matisms by friction, blows, and direct injuries of nerves ; blisters ; 
exposures to the direct action of the sun ; and obscure disturbances 
of the nervous centre that are difficult to appreciate. In one case, a 
young woman with a series of circumscribed patches along the inner 
face of the right thigh, could scarcely endure the fatigue of exposure 
of the part while an oil painting was made of the disks ; another case 
was that of a muscular blacksmith, who exhibited a large plaque of 
morphcea over the trunk. Scleroderma has occurred as a complication 
of Graves' disease, and in association with Raynaud's disease, lepra, 
sclerodactylia, Addison's disease, and other morbid states. 

The etiological importance of the nervous system is too obvious to 
require demonstration. This fact is much more distinct in the local- 
ized manifestations of the disorder, in which a region supplied by 
a single nerve or traversed by a nervous trunk is solely involved. 
Harley, Schwimmer, and others have recognized cardiac and gastric 
disturbances ; Westphal and Eulenberg, central and peripheral changes 
in the nervous system ; Heller demonstrated in one case closure of the 
thoracic duct. Bancroft 1 repeatedly recognized nlarise in large num- 
bers in the blood of a young girl in Australia who was affected with a 
characteristic scleroderma. Atrophy and other changes in the thyroid 
gland have been noted by Hektoen, 2 James, 3 Uhlenhuth, 4 and others. 

Pathology. 5 — The confusion which has existed in relation to the ques- 
tion of the identity of scleroderma and morphcea is due to various 
causes. By several authors similar symptoms are described under each 
of the two names ; and the symptoms described as peculiar to each are 
occasionally seen either simultaneously or successively in the same 
individual. 

Microscopical examination of the structures involved in the disease 
has proved unsatisfactory. The connective tissue of the skin has been 
found, according to Kaposi, indurated and thickened ; its elastic fibres 
multiplied at the expense of the panniculus adiposus ; its muscular 
tissue hypertrophied ; the pigment in the rete and corium increased ; 
the sweat-glands dilated ; the lumen of the blood-vessels diminished, 
and their walls ensheathed in accumulations of what he terms " lym- 
phatic cells." 

The nature of the pathological process in scleroderma is unknown ; 
no characteristic changes in the nervous centres have yet been appreci- 
ated. In the generalized form the two vascular systems, the sanguine 
and the lymphatic, exhibit within and about the walls of vessels embry- 

1 Lancet, 1886, i., p. 380. 

2 Centralbl. f. allgem. Path. u. An&L, 1897, viii., p. 673. 

3 Scottish Med. and Surg. Jour., 1899. 

* Berlin, klin. Wchnschrft., 1899, xxxvi., p. 207. 

5 For a histological study of the circumscribed forms, with bibliography, see Zaru- 
bin, Archiv, 1901, xiii., p. 188. 



SCLERODERMA. 553 

onic cells which become converted into fibro-plastic bodies. This 
change produces in parts an increase in the tunica media until it is 
twice its normal thickness. The lumen of the vessels is thus obstructed 
and at times obliterated, indicating that the essential process is an 
endarteritis obliterans, inducing, in the areas to which each twig of 
vessels is distributed, an exsanguinated state with a surrounding 
hyperemia. The latter accounts for the peripheral halo of the circum- 
scribed forms of the malady. That there is at the same time lymphatic 
obstruction is clear, with, either from the one cause or the other, an 
overproduction of connective tissue and elastic fibres in the areas of 
involvement. The corium is commonly hypertrophied, at least in the 
papillary layer ; while the subcutaneous tissue and panniculus adiposus 
are proportionately thinned ; and even at times, as suggested by the 
clinical features noted above, may wholly disappear. The pigment 
commonly vanishes from the prickle-layer ; the coil-glands at first are 
dilated, and later may disappear when the atrophic stage is reached. 
In the late circumscribed forms the papillae of the corium may also fall 
into atrophy, and the superior vascular plexus of the corium may 
undergo obliteration by thrombosis (Crocker). The compression of 
both glands and vessels is supposed to account for the final sclerotic and 
cicatriform condition of the advanced cases. 

Diagnosis. — In vitiligo there is an entire absence of all structural 
cutaneous changes and the skin has a characteristic milky-white color, 
the hairs of the part being also blanched. Both the pigmented 
macules and atrophic patches of lepra are remarkable for their anaes- 
thetic or hyperaesthetic symptoms, and their coincidence with, or se- 
quence from, other readily recognized symptoms of the disease, such as 
tubercles, bullae, ulcers, and involvement of the hairs, nails, eyes, and 
other organs. 

In sclerema and oedema neonatorum the age of the patient would 
serve to distinguish the disorders from scleroderma. In cancer en 
cuirasse (papillary cutaneous carcinoma), chiefly of the skin of the 
breast in women, but encountered elsewhere, the resemblance to 
scleroderma is striking ; and eminent surgeons have confounded the 
two. In both affections the skin, especially that of the thorax, is 
converted into a dense leathery cuirass, but the distinction is made as 
follows : first, the carcinomatous condition of the skin may be secondary 
to a cancerous change in the breast or nipple, in which case the doubt 
is readily removed ; second, if primary, the firm, isolated, and deeply 
tinted nodules of cancer are readily distinguished, projecting from the 
dense peripheral cutaneous infiltration ; third, the oedema and lymph- 
angitis associated with cancerous involvement are most often unilat- 
eral, and are limited very distinctly to the arm on the side of the body 
most seriously involved; fourth, the line of demarcation of the can- 
cerous change, while indeterminate on one side, is usually at the edge 
of advance distinguishable by tongue-like erythematous prolongations 
of a dull-reddish hue ; lastly, the tendency to ulceration, the coincident 
and resulting cachexia, the possible axillary adenopathy, and the rela- 
tively rapid and fatal result in cases at all liable to be confused with 
scleroderma, point severally to the truth. 



554 HYPERTROPHIES. 

In ichthyosis the congenital history, the presence of ichthyotic 
plates over the affected surface, and the general conservation of the 
health of the patient suffice to identify the disease. 

In progressive lenticular melanoderma (angioma pigmentosum et 
atrophicum) the melanotic condition of the skin, in connection with 
warts, tumors, ulcers, and limitations of the disease to the exposed 
parts, suffice to distinguish its character. 

Treatment. — In the management of symmetrical or generalized 
scleroderma the influence of climate should be considered. More im- 
provement is secured for these patients after removal to a dry equable 
climate than can be obtained elsewhere. If they must remain under 
unfavorable climatic influences, the body should be well protected by 
woollen, over muslin, silk, lisle- thread, or balbriggan undergarments; 
and while an outdoor life is desirable, such exposure should always be 
avoided in unfavorable weather. Internally cod-liver oil, the ferru- 
ginous tonics, and the nutrients generally are often indicated, as well as 
a roborant and generous diet. Thyroid extract has given good results 
in a small percentage of the cases in which it has been tried. Phillip- 
son l reports relief of severe diffuse scleroderma by the internal adminis- 
tration of salol in doses of from 2 to 3 grammes daily. Hebra 2 reports 
good results in three cases from intramuscular injections every second day 
of 10 minims of a 15 per cent, alcoholic solution of thiosinamin. The 
employment of potassium iodide, arsenic, mercury, and other remedies, 
such as lithium benzoate, sodic bicarbonate and salicylate, and the alka- 
lies, supposed to be indicated by the rheumatoid symptoms, have been 
alike praised and condemned by men of eminence on both sides of the 
Atlantic. Remedies of the reconstituent order should always first be 
employed and no resort be had to others save in emergency. 

The local treatment is by baths, massage, galvanism, alternate hot 
and cold douches or the actual cautery over the spinal column. Fol- 
lowing the daily salt-and- water or alkaline bath of a temperature suited 
to the season of the year and the physical condition of the patient, 
inunctions with cod-liver oil, lanolin, lard, or vaselin, neat's-foot oil 
slightly scented, or other simple oil or ointment, may be used. To 
these may be added with advantage in many cases 2 to 10 per cent, of 
the oleate of mercury or of ammoniated mercury or salicylic acid. In 
morphcea Brocq employs electrolytic puncture as in the treatment of 
hypertrichosis. Mercurial plasters are applied in the intervals of each 
sitting. We have employed radiotherapy in circumscribed sclero- 
derma without satisfactory results. 

Prognosis. — Symmetrical diffuse scleroderma, well treated in young 
subjects, usually results favorably without impairment of the general 
health. When atrophic changes occur the skin may recover its supple- 
ness and pliability, but this cannot be assured. Deformity in either 
event may complicate an otherwise favorable issue. In a proportion of 
cases the disease becomes so extensive and severe as to produce a fatal 
marasmus ; more frequently death results from intercurrent disorders. 

In circumscribed patches (morphcea) the majority recover without 
serious consequences ; the few go on to sclerosis of subcutaneous 
structures and consequent deformity. In the most of the simpler 
cases the disease from first to last seems to have but a local significance. 



PLATE XV. 




Elephantiasis Telangiectodes of the Upper Lip and Portions 

of the Face. 



ELEPHANTIASIS. 555 

ELEPHANTIASIS. 1 

(Gr. tttyag, elephant.) 

(Elephantiasis Arabum, Pachydermia, Bucnemia Tropica, 
Elephant Leg, Barbadoes Leg, Cochin-leg, Spargosis 
Fibro- areolaris ; Hypersarcosis j Sarcoma Mucosum. Fr. y 
Mal de Cayenne.) 

By the term elephantiasis is understood generally a more or less 
circumscribed hypertrophy of the skin and underlying structures, 
affecting any portion of the body, but especially the lower extremities, 
the external genital organs of both sexes, the inguinal regions, and, 
more rarely, the upper extremities, mammary region, the buttocks, 
parts of the head (ears), and with great rarity the tongue. 

The symptoms of the disease as detailed below are recognized as 
differing both in their etiology and their characters, according as the 
obstructive embarrassment is due to mechanical or other interference 
with the circulatory system, or to the preseuce, either in the lymphatic 
or blood-vascular channels, of Filaria sanguinis hominis. 

The disease is more common in the tropics, where it is usually of 
parasitic origin ; but sporadic cases are of occurrence in all countries, 
and are not very rare in portions of the United States. The most fre- 
quent seat of elephantiasis is the lower extremity of one side, where the 
foot, the leg (Fig. 60), or also the thigh of the same limb, may enlarge. 
The penis and scrotum of men (Fig. 61), the labia and clitoris of 
women, the upper extremities, the face, the ear, and portions of the 
trunk likewise may become involved. 

Symptoms. — The disease is at times insidious in its approach, and 
generally chronic in its career, but may be ushered in with severe rigors, 
prostration, delirium, and fever. Usually, localized inflammations pre- 
cede, as a cellulitis, an erysipelas, or a dermatitis, with or without involve- 
ment of the lymphatic vessels or glands. At the same time there is 
a condition of general fever (elephantoid or filarial fever), to which 
succeeds a defervescence, Avith abatement of the local inflammation, its 
sequels becoming manifested in a more or less persistent oedema of the 
part lately inflamed. After intervals of days, weeks, or months the 
pyrexia recurs with still greater involvement of the swollen tissues, 
which, with each access of fever, increase in volume and gain in density. 
When the elephantiasic condition is fully developed, the skin is tense, 
glossy, and blanched ; or wart-covered, ichthyotic, pigmented in various 
shades, its follicles patulous, its glandular structures either hyper- 
trophied or atrophied, its hairs thinned and roughened, the nails cor- 
respondingly changed (onychauxis), with loss of lustre. Pressure upon 
the oedematous part is followed by slight pitting, but the tissue beneath 
is felt to be brawny and indurated. The parts beneath the skin are 
increased perceptibly in volume, especially the subcutaneous tissue ; and 

1 For a detailed presentation of the subject, see Manson, Tropical Diseases, p. 520. 
and numerous reports and papers by the same author, from 1876 to 1899 ; and Scheube^ 
Falcke, and Cantlie, Diseases of Warm Countries, p. 392 (full bibliography). 



556 



HYPER TR OP HIES. 



the circumference of a limb thus diseased may be several times larger 
than that of its fellow. A lymphangitis is usually declared by painful, 
cord-like, linear indurations of the part, associated with adenopathy of 
the nearest ganglia. In older cases the skin loses its glabrous aspect, 
and exhibits eczematous, verrucous, papillomatous, seborrheic, and even 
ichthyotic changes. Pigmentation, even to a blackish tint, may ensue ; 
scaling, Assuring, and furrowing are common ; and the accumulation 
of altered sweat and sebum in these depressions is the source of an of- 
fensive stench. During the course of the disease almost all the ele- 
mentary lesions of the skin may be displayed : macules, vesicles, pap- 
ules, tubercles, pustules, blebs, ulcers, crusts, scales, excoriations, and 
fissures. Warty growths form as large as those seen in ichthyosis hys- 
trix, and in some cases reddish-colored tumors spring from the hyper- 
trophied integument. 

When fully developed in the lower extremity, the unwieldy limb, 
increased threefold and more in bulk, with the foot, ankle, and leg 
massed into one huge, cumbrous cylinder, bears a striking resemblance 
to that of the elephant, from which circumstance the malady first re- 
ceived its name among the Arabs. Locomotion then is impeded greatly 
or is rendered impossible. Not less striking is the similar deformity 
of the genital labia of women or the scrotum of the male, the latter at 
times hanging below the knees even as far as the ankle (Fig. 61). 

The penis disappears in rugous folds, and the urine passes along 
a gutter formed of skin transformed 
into quasi-mucous membrane. As a FlG 61 

consequence of the fissures and ex- 
coriations which form the lymphatic 
channels may be opened finally, and 
a true lymphorrhoea results. 

Fig. 60. 




Elephantiasis of the foot and leg. 



Elephantiasis scroti. 



Subjectively, the disease may be regarded as productive of less dis- 
comfort than would be suggested by its formidable features. Pain is 
experienced occasionally, and during the exacerbations accompanied by 



ELEPHANTIASIS. 557 

pyrexia there is corresponding malaise. The chief subjective sensations 
are those induced by weight and consequent tension, inseparable from 
the enormous masses of hypertrophied tissue. 

In elephantiasis of the scrotum there are frequently symptoms of 
irritation, both systemic and in the vicinity of the affected part (nausea, 
vomiting, inguinal pain and adenopathy, epididymitis, effusion into the 
sac of the tunica vaginalis, inflammatory swelling of the spermatic cord, 
and at times hernia). In some cases vascularization of the surface 
(telangiectatic elephantiasis) is a prominent feature. The form described 
below as Nsevoid elephantiasis may belong either to the same category, 
or to others in which there is lymphangiectasis (" lymph-tumors/' 
" lymph-scrotum "), and these may be due either to lymphatic obstruc- 
tion or to the parasite described later as of etiological importance in 
this connection. 

Lymph-sckotum (Varix Lymphaticus, Nevoid Elephan- 
tiasis). — Lymph-scrotum may be the precursory stage of elephantiasis 
of the same part. Commonly an attack is announced by the occur- 
rence of fever, soon followed by erythematous redness of the scrotal 
envelope, followed by vesiculation and the development of blebs. The 
bursting of these is the source of the continuous drain which ensues. 
The scrotum becomes more or less enlarged, and, though soft to the 
touch, is the seat of multiple, often numerous, lymphatic varices, which 
on puncture or spontaneous rupture give exit to a rapidly coagulating 
lymph or chyle. Several ounces of a clear or lactescent fluid may 
escape in an hour, and the discharge persist to the point of producing 
grave physical exhaustion. Inguinal and femoral adenopathy may be 
present. Often there are recurrent chills, fever, erysipelas, abscesses, 
and the localized inflammations occurring in elephantiasis of other 
organs of the body. 

Etiology. — The causes of elephantiasis are different in several of the 
disorders designated by that name. The most common factor, in the 
countries where elephantiasis is prevalent, is the presence in the body 
of Filaria sanguinis hominis, which can be recognized in the blood of 
the majority of natives of such countries. Living filarise have been 
demonstrated in blood-vessels placed under the microscope. The life- 
history of this parasite, Filaria nocturna, is detailed below : 

The parasite is sought for best late in the evening, a drop of blood 
being transferred to the microscope-slide by the usual methods, the 
glass having previously been dipped in water, to each 30 c.c. of which 
have been added three drops of a saturated alcoholic solution of 
fuchsin. The embryo is recognized as a transparent, serpent-shaped, 
colorless organism exhibiting great activity by wriggling motions, 
which, however, do not greatly change the position of the worm. One 
extremity of the parasite is abruptly rounded ; the other for about one- 
fifth of the entire length tapers to a fine point. The worm is en- 
closed in a delicate, limp, structureless sheath, or sac, longer than the 
contained worm. Manson believes that the function of this envelope 
is prevention of the puncture of the tissues of the animal in which it 
lives, prior to future development in an (i intermediate host." Deli- 



558 HYPERTROPHIES. 

cate transverse striae can be recognized in the musculo-cutaneous layers 
of the entire length of the animal. A shining triangular V-shaped 
patch usually can be seen at a point about one-fifth of the entire length 
back of the head-end ; and a similar but smaller spot is visible at a 
short distance from the end of the tail. These points are believed to 
be connected with the evolution of the embryo into the mature parasite. 
The head-end is capable of projection and withdrawal from a delicate 
prepuce having six lips, or hooks, a short thin fang being often shot 
out from the uncovered cephalic extremity. 

The periodicity of filarise is well marked in most cases under obser- 
vation, the embryos swarming in the circulation at night and disap- 
pearing during the day. Manson estimates that at midnight there may 
be forty or fifty millions of embryos simultaneously circulating in the 
vessels, all of which may disappear by 8 or 9 o'clock in the morning, 
the hours of activity being reversed when the filarial subject habitually 
sleeps during the day and is awake at night. 

The intermediate host of the filaria is the mosquito (the females of 
some family of the genus Culex), which after feasting on the blood of a 
filarial subject are found to have the stomach gorged with living em- 
bryos. The viscidity of the ingested dehydrated blood prompts the 
filarise to struggle until freed from their sheaths, when they begin a 
distinct locomotion for the first time in their life-history, — now enter- 
ing the thoracic muscles of the insect, and here, as elsewhere in the 
body of the intermediate host, undergoing in a period of from ten to 
twenty days a metamorphosis resulting in the formation of a mouth, 
an alimentary canal, and a trilobed tail. A considerable increase is 
now noted in their size. The vast majority then pass forward through 
the prothorax and neck of the mosquito until they enter the head, 
where they lie coiled up closely to the base of the proboscis, beneath 
the pharynx and under surface of the cephalic ganglia. The parasites 
may remain in this position until they have the opportunity of enter- 
ing, by the attacks of the mosquito, into the body of a warm-blooded 
vertebrate host, refusing, as shown by experiments, to quit the mos- 
quitoes which have been fed for long periods of time upon bananas. 

Once reintroduced into the human body, sexual maturity is reached, 
fecundation ensues, and in due course generations of embryo filarise are 
poured into the lymph. These passing through any intervening glands 
by way of the thoracic duct and the left subclavian vein, or by the 
lymphatics of the upper segment of the body, finally appear in the 
blood. 

Other disturbances due to the same parasite, and only in part recog- 
nized as elephantiasic, are the lymph-scrotum described above, chylous 
abscess, effusions, and vascular and hypertrophic enlargement of tissue 
and glands in and about tumors of the sort recognized as parasitic. 

In other cases different causes are to be recognized. Predisposition 
of races or individuals, heredity, climatic influences, malaria, fatiguing 
labor with the feet and legs immersed in water, and filth in connection 
with " misery," have all been cited as favoring conditions. To these 
causes should be added the local disorders especially common in the 
lower extremities that have in cases proved to be points of departure of 



ELEPHANTIASIS. 559 

elephantiasic hypertrophy, such as obstruction to the blood or lymphatic 
currents by pressure of tumors, pregnancy, or neoplasms ; ulcers, cica- 
trices, and traumatisms by pressure or friction ; cutaneous diseases ; 
systemic affections (syphilis, tuberculosis) ; and osseous disease. 

Pathology. — Even macroscopically the elephantiasic mass is seen to 
be built up of hypertrophic elements representing all the tissues of 
which the part is composed. The knife with difficulty divides the 
homogeneous, whitish, and lardaceous mass, from which on pressure 
exudes a fluid of similar color. The subcutaneous connective tissue is 
found relatively much more enlarged and sclerosed than the epidermis 
and derma ; though when section is made through the rugous and warty 
skin described above, all the elements of the papillary layer, rete, and 
stratum corneum are seen to participate in the changes described in 
connection with the pathology of verruca. Here and there are loculi 
filled with fluid lymph. The sheaths of the blood-vessels, lymphatics, 
nerves, and the bones, muscles, and aponeuroses are also thickened, 
solidified, and occasionally agglutinated, so as to be almost indistin- 
guishable in the mass of uniformly sclerosed tissue. The pigmentation 
of the derma is marked, the nuclei of the connective-tissue cells are 
multiplied, and the cutaneous glands intact, hypertrophied in their 
epithelial linings and investments, or, at a later stage, atrophied. 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands and 
vessels, the whitish and yellowish lymphatic fluid which then accumu- 
lates in the tissue resulting from obstruction of the lymph-channels. 
In some of the remarkable cases on record the lymphatic obstruction 
is the prominent feature of the disease, and the elephantiasic enlarge- 
ment is subordinate in gravity to the former condition. Such are, for 
example, the noteworthy instances in which the lymph distends mul- 
tiple cutaneous vesicles, after rupture of one or more of which the fluid 
streams away to a dangerous extent. 1 

Diagnosis. — The striking deformity which characterizes elephan- 
tiasis will always suffice for its recognition. In the earliest stages of 
the disease, when there is merely oedema or an erysipelatous or eczema- 
tous condition of the skin, it would be difficult, if not impossible, to 
decide as to the future of the disorder, especially in a locality in which 
only sporadic cases occur. A symmetrical hypertrophy of both legs 
and both feet, developing in America, even though described as " ele- 
phantiasis," should carefully be studied before a diagnosis is made of 
the particular disease here considered. The same might be said of 
elephantiasis of but one inferior extremity. A patient with an exten- 
sive deforming induration and enlargement of the right leg and foot, 
accompanied by pigmentation and a well-marked warty condition of 
the skin, who had been pronounced the victim of idiopathic elephan- 
tiasis Arabum, had received a fracture of the upper third of both bones 
of the same leg during the previous year, and had since the accident 
constantly worn a tight bandage encircling the limb at the seat of the 
injury. The deformity rapidly disappeared under the application of a 
roller bandage extending from the toes upward. 

1 For a fuller description of this class of cases the reader is referred to Busey's 
monographs on Occlusion and Dilatation of the Lymph-channels. 



560 HYPERTROPHIES. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women — most commonly the labium majus of one side — 
results from a syphilitic, gummatous infiltration which must be distin- 
guished from elephantiasis. In cases of this kind the history of the 
patient and the relative inferiority as to bulk of the affected organ point 
to the nature of the disease. The syphilitic labium rarely exceeds the 
size of a large fist. 

A gigantic, hypertrophied mass of elephantiasic type is occasionally 
to be discovered in the lower extremity of only one side in patients who 
have been for many years the victims of an unrecognized and long- 
untreated syphilis. Even when the leg is many times its normal size 
and weight, and its contour lost in a thickened and roughened epidermis 
resembling the bark of a tree, the diagnosis may be made by discover- 
ing here and there in the depth of the mass circular and characteristic 
scars of healed gummatous ulcers. 

Treatment. — In the early stage of elephantiasis the febrile condi- 
tion of the patient and the localized cutaneous inflammation are to be 
treated by the measures appropriate for the relief of these conditions. 
Quinine, especially in malarial districts, is of the highest importance. 
When the elephantiasic development is established, if the genitals are 
involved the knife of the surgeon offers the best prospects. The result 
of such interference, both in the genitalia and the extremities, has in 
many cases been brilliant, though the mortality of such severe opera- 
tions is necessarily great. When the lower extremity is involved it 
should be maintained in a horizontal position, its ulcers if possible be 
healed, its excrescences removed, its circumscribed inflammations 
resolved, and then elastic compression be carefully and skilfully main- 
tained by means of a rubber bandage. Similarly the elephantiasic 
scrotum or labium majus requires elevation and constriction prior to 
operative interference. The toes are first separately enveloped, then 
the foot and ankle, and lastly the leg. The results are sometimes 
highly satisfactory. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg have occasionally been followed by transient improve- 
ment. Instrumental compression has at times resulted in severe ulce- 
ration and a reawakening of the erysipelatous affection. Multiple 
punctures and incisions, made with a view to giving exit to the fluids 
contained in the mass, have been attended by no greater success. The 
main obstacle in all these surgical procedures is the lymphangitis 
which so frequently complicates the situation. None of them promises 
so well as nerve-stretching, which in a few isolated cases has been fol- 
lowed by noteworthy results. Excision of a portion of the sciatic 
nerve has also been followed by satisfactory changes. The use of the 
galvanic current has, when long continued, accomplished resolution of 
engorged masses of tissue. Elastic compression in the horizontal posi- 
tion for all cases not warranting nerve-stretching may be regarded as 
the wisest course when the extremity is involved. For the local treat- 
ment of the pachydermia proper, green soap, mercurial ointment, and 
bathing with hot or cold lotions may advantageously be employed. For 
patients whose disease is acquired in countries where the deformity is 



ACROMEGALY. 561 

prevalent a change of climate is of the highest importance ; and, having 
in view the social surroundings and habits of most victims of the dis- 
ease, it is scarcely necessary to call attention to the need of a proper 
hygiene, diet, and tonic regimen. 

Prognosis. — The future of a patient may be regarded as most favor- 
able when the disease exhibits an early tendency to respond favorably 
to appropriate treatment, and when circumstances permit of a resort to 
the best therapeutic measures which can be adopted, such as change of 
residence, persistent and careful dressing of the affected part, and the 
removal of any exciting cause of the disease, such as neoplasm, an 
indurated cicatrix, etc. In the severer cases a fatal result may occur 
early in the disease ; but usually life is prolonged, burdened by the 
inconvenience of the enormous "elephantiasic mass in comparison with 
which the rest of the body often seems to serve as a mere appendage. 

ACROMEGALY. 1 

(Gr. ciKpog- } extremity; \izyaLri, great.) 

Acromegaly is a disorder involving several organs of the body and 
incidentally the skin. 

Symptoms. — Transitory swellings due to vaso-motor changes affect- 
ing the face and hands often precede for some time the classical mani- 
festations of the disorder, which include cephalalgia, rachialgia, and 
paresthetic symptoms suggesting hysteria. These are followed by 
characteristic thickenings of the bones of the hands and the feet, 
spreading at times to the foot and the leg, and involving also the face, 
especially the under jaw. In well-marked cases the under incisors 
project beyond the line of the teeth ; the maxillary, malar, and occipital 
bones are thickened ; the nose becomes long and broad ; and the under 
lip, ears, tongue, and larynx, are deformed by thickening. The fingers 
are large, blunt-pointed (" drum-stick deformity "), and tipped with 
nails that appear smaller than normal in comparison with the bulbous 
digits. The so-called " hexagonal face " is thus produced. In con- 
nection with these symptoms there may be interference with articula- 
tion due to thickening of the tongue, a rough sound to the voice (from 
laryngeal changes), motor disturbances, and exophthalmos. 

The skin and mucous membranes are often the seat of changes. 
In the skin there may be pigmentation, sclerosis, hyperidrosis (often 
coincident with polyuria), hypertrichosis, and the formation of keloid 
at points of trivial traumatisms. The nails are thickened, flattened, 
and grooved. The subcutaneous fat often is increased. At times there 
is an almost characteristic engorgement of the skin of the cheeks, 
which taken together with the altered contour of the face described 
above, furnishes a classical picture. 

1 For bibliography, see Marie, Eev. de Med., 1886, vi., p. 297; Marie and Mari- 
nesco, Trans. Derm. Cong., Berlin, 1890; Souza-Leite, De 1' Acromegalic, Paris, 1890 
(abstr. of 49 cases) ; Collins, Jour. Nervous and Mental Dis., 1893, xx., p. 48 (biblio- 
graphy) ; Arnold, Virchow's Archiv, 1894, cxxxv., p. 1 (with list of cases published 
since 1890). Shallcross, Phila. Med. Jour., 1901, vii., p. 771 ; and Kuh, Jour. Amer. 
Med. Assoc, 1902, xxxviii., p. 295 (full bibliography). 

36 



562 HYPERTROPHIES. 

Etiology. — The disease occurs in both sexes, more often in man 
and most frequently after the puberal epoch, though it may develop 
before that period and at an advanced age. 

Pathology. — The precise nature of the changes occurring in acro- 
megaly and their relation to myxoedema, and the thyroid diseases in 
general, are not understood. Frequent anomalies have been recognized 
in the thyroid gland, as also persistence of the thymus. Many believe 
that the disease is due to tumors of the hypophysis, a condition often 
recognized in the same connection. In twelve of fifteen autopsies 
made by Hanseman the gland was enlarged in twelve : the tumors 
recognized being adenomatous, gliomatous, sarcomatous, etc., sup- 
posedly as a result rather than as a cause of the morbid condition of 
the bones and other parts affected. In women there are often amenor- 
rhoea and atrophy of the uterus. 

Diagnosis. — The " drum-stick deformity " of the fingers and toes, 
in connection with the characteristic " hexagonal face," usually suffices 
for recognition of the disease when studied in connection with the other 
symptoms present. The occurrence of these symptoms in a male sub- 
ject of adult years who belongs to the lower classes of society with 
respect to food and hygienic environment should suggest the presence 
of acromegaly. 

Treatment. — The therapy of the disease is unsatisfactory : the use 
of the thyroid extract and of the animal extracts in general, including 
the pituitary substance, has been productive of little if any benefit. 

Prognosis. — The future of the patient is clouded with the prospect 
of continuance of the symptoms for an indefinite period, with a marked 
liability to intercurrent affections. A few of those affected survive 
without impairment of mental and physical vigor. 



CLASS V. 
ATROPHIES 



LEUCODERMA. 

(Gr. TievKoq , white ; 6kp[xa y skin. ) 

(Achromia, Leucasmus, Partial Albinism.) 

Absence of the pigment of the skin and hairs giving rise to con- 
spicuous disfigurement is naturally most frequently encountered in 
those races of mankind whose skins are most abundantly provided 
with such pigment. The absence of pigment may be congenital or 
acquired, and be partial or universal. Some confusion has been pro- 
duced by the arbitrary distinction established by authors between the 
names intended to designate these several varieties of achromia or 
leucopathia. In the following pages leucoderma is the name employed 
to designate the pigment-atrophy which is partial and congenital ; al- 
binismus, that which is universal and congenital ; vitiligo, that which 
is acquired. 

In leucoderma, the patients being most often, though not exclusively, 
of the colored races, one or several whitish or rosy-whitish patches or 
bands, varying in size, outline, or situation, unprovided with pigment 
may be seen at birth. These patches may have a symmetrical arrange- 
ment, in which case they commonly observe the areas of distribution of 
one or more cerebral or spinal nerves ; or they are asymmetrical in distri- 
bution. They are usually of circular outline, and may be found upon 
the scalp, face, nipple, breast, and genital and other regions. The hairs 
found upon such parts are equally destitute of normal color, being usually 
white. Negroes thus marked are generally termed " piebald," and the 
integument similarly affected in persons of other races has long been 
recognized as the " pied " or " piebald skin." These blemishes when 
symmetrical, like pigmentary nsevi, exhibit a striking analogy with the 
symmetrical arrangement of the spots, bands, and stripes to be recog- 
nized in the furs of many of the lower animals. The outline of the 
patch may be abrupt, or it may gradually shade into that of the adja- 
cent integument. At times islands of pigmented skin are visible within 
the non-pigmented areas. The changes in these patches during later 
life may be insignificant, or they may individually increase in size with 
age, or even multiply. Rarely they regain pigment in later life. In 
no case is there an excess of pigment deposited at the border of the 
patch. 

This condition is practically remediless. 

563 



564 ATROPHIES. 

ALBINISMUS. 

• (Lat. albus, white.) 

(Complete Congenital Leucoderma, Congenital Leukasmus, 
Congenital Achromia, Congenital Leukopathia.) 

Symptoms. — The term albinismus is here limited to the congenital 
conditions of achromia induced by universal absence of cutaneous pig- 
ment. 

This deformity is peculiar to individuals known as "albinoes" 
(Kakerlaken; Dondos), isolated instances of this anomaly occurring 
in all races, but more frequently among those having normally a hyper- 
pigmentation of the skin, such as negroes. In the subjects of this 
anomaly the skin has a milky- whitish, transparent, or rosy-tinted hue, 
and is usually of delicate texture; the hairs are silky and yellowish, 
reddish, whitish or snowy- white in color; the iris transparent or pinkish ; 
and the pupil, in consequence of defect of pigment in the choroid, is also 
reddish or pinkish. There are, as a result, nyctalopia and heliophobia, 
with frequent nictitation, pupillary variations, and the semblance of 
myopia. The pinkish hue of the skin in these individuals is due only 
to its translucency and vascularity. The defective condition of the 
pigment is usually unchanged throughout life ; but in no other respect, 
save as to pigment-anomaly, does the skin of the healthy albino indi- 
cate disease. 

Many persons thus deformed, however, are far from vigorous. It 
has been observed that some albinoes are physically inferior to the 
average of persons of the same sex, both in stature, weight, mental 
activities, and powers of resistance to disease. There are, however, 
numerous striking illustrations of the reverse of this, and we have had 
under observation a number of albinoes in one family in which alterna- 
tions of non-pigmented with normally pigmented children exhibited 
no difference whatever in sturdiness and vigor. Many enfeebled 
albinoes are simply illustrations of the wretchedly unwholesome life of 
persons imported for exhibition into foreign countries. 

Etiology. — Inheritance is evidently a strong factor in the produc- 
tion of this and similar pigment-anomalies. Alternations in birth of 
white and of black children in one family are recorded, yet it is un- 
usual to find albinoes in two succeeding generations, an occurrence of 
no great rarity in inherited affections. 

The condition is remediless ; though it is probable that transfusion 
with the blood of a vigorous black-skinned African would largely 
modify the color-characteristics of the pure albino. 

In Marcy's l report, a black father and mother had first two black 
male infants, then two female albinoes, then a black female child, and, 
lastly, a male albino. We recently exhibited in our clinic twin albinoes, 
children of Irish parents. In Syrn's 2 cases, the first, third, fifth, and 
seventh children were albinoes. 

1 Amer. Jour. Med. Sci., 1839, xxiv., p. 517. 

2 Trans. Lond. Ophthal. Soc, 1891, xi., p. 218. 



VITILIGO. 565 

VITILIGO. 

(Lat. vitium, a blemish.) 

(Acquired Leucoderma, Leukopathia, Leukasmus, Achroma, 

Piebald Skin.) 

Vitiligo is an acquired cutaneous achromia, exhibited in single or 
multiple, variously shaped and sized patches, unaccompanied by textural 
changes in the skin, and usually bordered by tissues exhibiting pig- 
mentary excess. 

Symptoms. — This disorder of the pigment of the skin is one ob- 
served among the several races, often in the negro, and not rarely 
among those of Aryan descent. It commonly occurs without the 
slightest appreciable disorder, subjective or objective, save that betrayed 
to the eye in the color-changes of the skin. One or several rounded, 
oval or very irregularly shaped, smooth, and well-defined, pale or 
milky-white lines, streaks, or disks appear, often bordered at the peri- 
phery by an integument which assumes a light- or dark-brown or 
chocolate shade, this hue being by contrast most- noticeable immediately 
at the contour of the patch, and imperceptibly fading into the normal 
color of the outlying integument. These patches are neither elevated 
above nor depressed below the general level of the integument. The 
patches may be few, numerous, or coalesce to the point of producing a 
generalized albinism. The hairs or lanugo-filaments growing from the 
affected ar»ea may or may not be blanched ; most commonly they are, a 
condition particularly conspicuous when, as is not rarely observed, a 
vitiliginous disk extends from the back or the side of the neck well 
into the scalp, in which case the outline of that portion of the scalp 
involved is clearly defined by the whitened pilary growth. Lesser 
describes a condition termed by him Peliosis Circumscripta Ac- 
quisita, in which the hairs were thus blanched in a single area of an 
unaffected scalp, an observation confirmed in many cases. 

The most common seats of the disease are the face, the neck, the 
backs of the hands, the genitals, the trunk, and the extremities. Upon 
the backs of the hands the disfigurement is usually more conspicuous 
in summer than in winter, a circumstance which probably explains the 
reported instances of recurrence and total disappearance of the disease 
in successive years. The changes are due to a deepening of the pigment 
in the normal areas on exposure to the sun, thus making a more striking 
contrast with the non-pigmented spots. 

The course of the affection is exceedingly slow; there may be for 
years no apparent extension of any involved area or the achromia may 
progress by peripheral extension and by the coalescence of relatively 
small affected areas until a large portion of the trunk, the thighs, the 
buttocks, or other part of the body is involved. Hall * reports the case 
of a dark mulatto who became " perfectly white," with the exception. 
of a patch on the chin. Levi 2 reports three instances of total disap- 

1 Louisville Med. News, 1888, x., p. 148. 

2 Receuil de Mem. de Med. de Chir. et de Pharm. mil., 1865, p. 193. 



566 



ATROPHIES. 



Fig. 62. 



pearance of pigment. Hardaway, 1 Simon, 2 and Stelwagon 3 also report 
cases in which the loss of pigment was general or complete. It not 
infrequently happens that the loss of pigment is so extensive on the 
face, hands, and other regions that the eye of the observer is struck no 
longer by the unusual whiteness of the involved patches, but this white- 
ness being generalized and apparently that proper to the person, the 
remaining normal areas appear to be hyperpig- 
mented. Patients with vitiligo frequently sup- 
pose that the whitened areas are normal, and the 
darker ones abnormally pigmented. Patients of 
lymphatic temperament and blonde complexion 
(often women in early adult life) occasionally will 
apply to a physician for relief of dark patches on 
the skin of the face. Examination discloses faint 
lines, ribbons, or streaks of pigment about one 
or both cheeks, the temples, or the lips. But 
careful scrutiny recognizes an undue whiteness 
of the skin, with exceedingly faint and irregular 
outline near or next to those pigmented portions 
of which complaint is made. In these cases care 
is necessary to make a diagnosis between vitiligo 
and chloasma. 

As in several of the other pigmentary dis- 
orders of the skin, the patches of vitiligo may 
be symmetrical in distribution, with their out- 
lines limited to the areas supplied by certain 
nerves. The disorder shows a tendency to spread, 
though as a rule a limit is reached eventually 
beyond which the atrophy does not progress. 
In exceptional cases the parts which have lost 
pigment again acquire it. 

The patch of skin from which the pigment 
has been removed is often exceedingly sensitive 
to the action of solar rays and to externally 
applied irritants chemical and others. It then 
exhibits a peculiar diffused pinkish shade of 
color occasionally with production of reddish 
papules, the disappearance of which never is 
followed by the pigmentation occurring in nor- 
mal skin after marked hyperemia. 

In vitiligo, aside from the dyschromia, the 
skin is normal. The health of the subjects of 
this disorder is usually unimpaired. A morbid mental condition, espe- 
cially in women of middle life, often is produced when the disfigure- 
ment involves the facial region. 

Etiology. — Vitiligo occurs in both sexes and in individuals of all 
complexions and ages, though it is observed commonly among women 

1 Manual Skin Diseases, 2d ed., p. 280. 

2 Deutseh- Klinik, 1881, p. 399. 

3 Amer. Jour. Med. Sci., 1885, xc., p. 168. 




Vitiligo in a negro boy, 
(Piffard's case.) 



VITILIGO. 567 

and in early or middle life. It may begin as early as the fourth year 
of life (Crocker), but rarely attacks those over thirty years of age. Its 
etiology must be regarded as obscure, although there are strong prob- 
abilities that it is due to the influence of perturbed innervation. It is 
found frequently in connection with functional and organic diseases of 
the nervous system and with peripheral nerve-lesions. It occurs in 
persons who have enlargement of the thyroid gland with and without 
the concurrence of Graves' disease l ; and has resulted from trauma- 
tisms, burns, blisters, ulcerations, pressure-effects, new-growths, expos- 
ure to cold, sunstroke, neuritis, and simple inflammatory diseases of 
the skin such as psoriasis. It is an occasional feature of alopecia 
areata, lepra, Addison's disease, syphilis (pigmentary syphiloderm), 
and scleroderma. The disorder is of more frequent occurrence than 
dermatological statistics tend to show. Many persons who are the sub- 
ject of vitiligo of an inconspicuous part of the body do not consult a 
physician with regard to the nature of the disease, as it occasions no 
physical distress. 

Pathology. — The pigment normally present in the deep rete-cells 
is absent in vitiligo-spots, but greatly increased and deepened at the 
borders of the areas. In the corium are cells which contain pigment- 
granules. These are especially numerous at the margins of patches, 
where blood-vessels, follicles, and glands are surrounded by many 
oval, stellate, and branched pigment-cells. The probable nature and 
origin of these cells are considered with chloasma. Leloir and Chabins 
have demonstrated atrophy of the subdermal nerves in patches devoid 
of pigment. Other changes in the skin have not been noted. 

Diagnosis. — The diagnosis is based on the achromia, with usually a 
hyperpigmented border, and the absence of other symptoms. In all 
typical cases the recognition of the disease is facile. The several 
chloasmata are distinguished by their failure to exhibit the distinctly 
outlined circular border of the characteristically developed vitiligo 
patch. Much attention has been given to the distinction between viti- 
ligo and the leucodermatous patches of anaesthetic lepra, but a study 
of the macular lesions in the disease last named reveals distinctly the 
presence of a systemic disorder with anaesthesia of the affected areas. 
Morphoea is distinctly a disorder of the skin accompanied by infiltration 
of the integument while vitiliginous patches are solely distinguishable 
by reason of the color-changes. The color, surface-scaling, and 
localization of tinea versicolor usually serve for its recognition, and the 
parasite always can be recognized by the microscope. 

Treatment. — Much chagrin will be saved both physician and patient 
by practically regarding vitiligo as not amenable to treatment. Patients 
occasionally recover while under treatment, which, however, has con- 
tributed generally but little to the result. Arsenic and iron internally, 
recommended highly by some others, have failed repeatedly to accom- 
plish any appreciable results as regards dyschromia. By efforts directed 
to the removal of the hyperpigmentation in the border of the achromic 
patches the disfigurement may be lessened somewhat. The method of 

1 Cf. Dore, Brit. Jour. Derm., 1900, xii., p. 353 ; Hyde and McEwen, Amer. Jour. 
Med. Sci., 1903, cxxv., p. 1000. 



568 ATROPHIES. 

arriving at this end is described in connection with the treatment of 
chloasma. It is possible that further experimentation with hypoder- 
matic injections of pilocarpine, that have in a limited number of cases 
been followed by disappearance of the disease, may Avarrant a less 
unfavorable view of the results of treatment. Savill 1 reported a 
return of normal color in vitiliginous patches to which he had applied 
pure carbolic acid. D. W. Montgomery 2 reports a case of vitiligo in 
which several applications of the Finsen light were followed by restora- 
tion of the normal pigment. We have tried the method in 4 cases 
with negative results. 

Prognosis. — The health of the subject of the malady is not impaired. 
The disease is practically incurable, progressing usually until it has 
obtained a maximum of development ; and then, as a rule, remaining 
unchanged throughout life. 

CANITIES. 

(Lat. canus, white.) 

(Trichonosis Cana, Poliothrix, Poliosis, Hoariness, Gray- 
ness or Whiteness of the Hair.) 

Symptoms. — In this anomaly the hairs appear in all shade of white- 
ness, from dirty gray or yellowish white, to a steel gray or silvery 
white. This may be either a general or a partial, congenital or acquired, 
physiological or pathological, prematurely, rapidly, or gradually 
acquired condition. General congenital whiteness of the hairs is seen 
in albinismus, where pigment has never colored the filaments. Partial 
congenital whiteness is occasionally seen in patches, limited in size 
and varying in color from pure white to a deeper hue, that from birth 
do not receive pigment in due proportion, thus contrasting with the 
pigmented filaments by which they are surrounded. 

Physiological decoloration of the hairs in variable shades is the 
well-known result of advancing years. When premature, it may 
occur early in life and result from pathological causes or be due to in- 
dividual or inherited peculiarities. It may occur gradually or sud- 
denly ; in the former case the hairs usually pass through varying 
shades of gray to white, and this at any period after (occasionally 
before) puberty, though commonly after middle life is reached. At 
first a few scattered hairs are bleached : then these multiply and so 
gradually the whitening occurs ; in other instances the bleaching is 
general, symmetrical, and uniform. In yet other cases even in senile 
hoariness the canities is at first circumscribed, the hairs of one part of 
the scalp blanching before others, the hairs of the beard whitening 
before the scalp or vice-versa. Recurrence to the darker shades is 
noted rarely. Leonard, of Detroit, 3 cites a number of curious in- 
stances in which changes of this sort have occurred. Generally, how- 
ever, canities of advanced years is progressive and permanent, occurring 

1 Brit. Jour. Derm., 1898, x., p. 99. 

2 Jour. Cutan. Dis., 1904, xxii., p. 17. 

3 The Hair, its Growth, Care, Diseases, and Treatment, Detroit, 1880. 



CANITIES. 569 

earliest on the temples and the beard of man, then involving the vertex 
of the head. Finally, the hairs of the entire body-surface may undergo 
similar pigmentary loss. 

The coloring of the hairs of the head is, to a greater extent than 
commonly is appreciated, subject to variation from the operation of ex- 
ternal causes. Thus, washing the hair with alkaline solutions has a 
bleaching effect, while profuse sweating, inunction with fats, subjection 
to smoke, and the temperature-changes of the summer have the con- 
trary influence, the last named being associated possibly with increased 
sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, in 
a single night, are sufficiently numerous and well authenticated to be 
admitted as among the rare possibilities of a clinical experience. Ner- 
vous disorders, both centric and peripheral, such as long-continued 
mental depression, melancholia, paralysis, neuralgia, and traumatism 
of nerves or of nervous centres, may be followed by more or less rapid, 
general or partial, and permanent canities. The same result may fol- 
low wasting disorders, such as typhoid fever, tuberculosis, syphilis, 
and malarial fever, in which cases, as distinguished from the others, 
pigmented hairs eventually may replace those which were white. The 
first hairs springing from a patch of alopecia areata in which repair is 
in progress are often white or whitish, and are replaced later by those 
of normal color. The pressure of a truss or of a corset has produced 
patches of vitiligo and canities. 

Landois has shown that many instances of suddenly occurring cani- 
ties depend solely upon the rapid appearance of air-bubbles in excess 
of the average number in the hair-shaft. 

Etiology. — Whitening of the hair may be senile in origin, in which 
case it is customary to declare it to be physiological ; or be due to 
heredity ; to deficient nutrition or innervation of the hair-follicles ; to 
functional or organic nervous affections (fright, facial atrophy, etc.) ; 
or to local chemical action upon the hairs. Premature canities in 
young adults is often associated with the occupations of life, being 
much commoner in men who from necessity have the head habitually 
covered and who yet lead sedentary lives. 

Pathology. — The color of the hair is dependent upon the pigment 
situated in the matrix and between the horny cells, and upon the 
natural yellowish color of the dried horny cells. In source and char- 
acter the hair-pigment is undoubtedly identical with that of the skin 
in general. This has been considered with chloasma. Decoloration 
of the hairs may be due to failure of supply or to removal of pigment ; 
to unevenness of the hair-surface (by which light is refracted) ; or 
to air-bubbles between and within the fibre-cells. In senile and pre- 
senile decolorations there is commonly actual diminution of pigment. 
Rapidly occurring canities is ascribed to the sudden appearance of air- 
bubbles in quantity in the shafts of the hair. Alterations of color in 
the hairs are attributed to successive periods of activity and rest in the 
pigment-producing cells. 

Treatment. — The chief means of remedying premature canities is 
by the action of dyes, which are, in the main, compounded with solu- 



gr. xv ; 
gr. xxij ; 

3j» 


1 

1 
30 


5 
M 


ffl; 

gr. xv ; 

gtt. xv ; 
ad f giij ; 


4 

1 

1 

ad 90 


M. 


gr. xv; 

3ss; 


1 

2 
45 


M 



570 ATROPHIES. 

tions of silver nitrate, lead acetate, and ferrous sulphate. The main 
objections to their use are the fact that the dyed hair never has the 
exact hue and lustre of naturally tinted filaments and thus rarely 
deceives the eye of the observer, as also the disagreeable coloring of 
the scalp which results from incautious use of the dye, and the conse- 
quent liability to irritation of the surface. These substances are not 
known to have a deleterious effect upon the general health. Kaposi 
gives the following formula? for hair-dyes : 
To obtain a black color — 

R Argent, nitrat., 
Ammon. carb., 
Unguent, adipis, 

Or 

R Argent, nitrat., 
Plumb, acetat., 
Aq. Cologn., 
Aq. ros., 

To obtain a brown shade — 

R Acid, pyrogal., 
Aq. Cologn., 
Aq. ros., 

Anderson first applies a lotion of mercuric chloride, 2 grains to the 
ounce (0.133 to 30.), and follows this with a solution of sodium hypo- 
sulphite, 1 drachm to the ounce (4. to 30.), for the production of a 
jet-black shade. In the way of constitutional treatment, he suggests 
in cases of accidental presenile blanching strict attention to the gen- 
eral health and arsenic internally. 

ALOPECIA. 1 

(Gr. alidTzr]^ a fox.) 

(Calvities, Defluvium Capillorum, Deficiency of Hair, 
Baldness. Ft., Alopecie; Ger., Kahlheit.) 

The simple term alopecia is no longer descriptive of a disease, but 
only of a symptom, loss of hair, which occurs in a large number of 
morbid and even physiological states. For convenience of description 
the alopecias may be enumerated as congenital, idiopathic and symp- 
tomatic, premature or presenile, and senile alopecia. Alopecia areata, 
being distinctly different from the affections generically associated with 
alopecia simplex, is considered separately in these pages. 

Congenital Alopecia. 2 — In rare cases there is a partial or complete 
absence of hairs at birth, in consequence of arrested development of 

1 For bibliography of disorders of the hair, see Jackson, Diseases of the Hair and 
Scalp, New York, 1890. 

2 For a review o f the subject, with histological report, and bibliography, see Bett- 
rnann, Archiv, 1902, lx., p. 343 ; and Kraus, Ibid., 1903, lxvi., p. 369. 



ALOPECIA. 571 

the pilary system, or the growth merely of downy, stunted, and poorly 
nourished filaments incapable of further development. Generally, how- 
ever, these appendages of the skin are merely of tardy appearance, 
their eruption being extraordinarily delayed, as in retarded dentition. 
In some instances the hair falls after birth and never returns. When 
the alopecia persists to adult years, as is rarely the case, there is usually 
defective development also of teeth and nails. In several reported 
cases a distinctly inherited tendency to calvities is evident, brothers 
and sisters, mothers and children being partially or wholly unprovided 
with hairs. Nicolle and Halipre, C. J. White, 1 and others report cases 
in which an inherited alopecia or dystrophy of the hairs was associated 
with dystrophy of the nails. 

In localized congenital alopecia hairs rarely develop after maturity, 
and here, also, abnormalities of teeth may be coincident features. In 
a case of congenital alopecia examined by Schede 2 the sebaceous glands 
were found opening on the free surface of the skin. In the deeper 
part of the cutis straight or convoluted hair-rudiments were visible in 
the tubules, without perceptible internal cavity, which corresponded 
with the external root-sheath. According to Hill, 3 there are hairless 
races illustrated among the Australian aborigines. 

Senile Alopecia. — The baldness of old age, whether occurring upon 
the vertex so as to produce a tonsure like that of the priest, or whether 
limited to the frontal region, or so extensive as to involve nearly the 
entire calvarium leaving a fringe of hairs at the occiput and temples 
merely, is always remarkable for its symmetry. There is, hence, a 
certain degree of dignity added to the appearance of the head that an 
asymmetrical loss of hair does not produce. It may occur at varying 
ages of advanced life, and is frequently traceable to an early seborrhoea 
sicca or alopecia furfuracea. It is much commoner in men than in 
women, largely because of the difference in the manner of covering 
the head in the two sexes, women usually wearing an exceedingly light 
dress for the head, while men encase the latter with tight-fitting caps 
or hats which interfere with proper aeration of the scalp. Individ- 
uals of the male sex, also, in consequence of their usually wearing the 
hair short, bestow far less time upon the care and dressing of it. In 
uncivilized races these differences are less marked, men pay great 
attention to the ornamentation of the scalp, and senile baldness is of 
less frequent occurrence. 

The bald surface, as a rule, is smooth and shining, the atrophy of 
the pilary system corresponding to that noticeable in other structures 
of the aged ; it is occasionally the seat of a seborrhoea oleosa. The 
hair-follicles, with their accessory sebaceous glands and occasionally the 
skin itself, are often in a state of atrophy, though there may be dilata- 
tion of the sebaceous glands. There is commonly blanching of the 
hairs, which are shed gradually, as also of those which remain, though 
the canities is not constant. This condition is much less frequent upon 
the surface covered by the beard and pubic and axillary hairs, where, 

1 Jour. Cutan. Dis., 1896, xiv., p. 220 (bibliography). 

2 Archiv f. klin. Chir.. 1872, xiv., p. 1. 

3 Brit. Med. Jour., 1881, i., p. 177. 



572 ATROPHIES. 

according to Michelson, the hairs in advanced years are often denser 
than at other periods of life. 

Premature or Presenile Alopecia (premature calvities) is that form of 
acquired baldness which occurs in individuals who have not attained 
advanced years. Idiopathic and symptomatic forms are recognized by 
writers, though it is probable that a definite cause exists for cases 
occurring in individuals under forty-five years of age. 

The Idiopathic variety does not originate in the diseases of the 
scalp or of the general economy that are recognized as effective in the 
production of other forms of baldness. " In many cases, however, 
classed as idiopathic a careful search will reveal the presence of a 
seborrhoea. It is, as with senile alopecia, more common in men than 
in women, and is in the former sex decidedly prevalent among those 
leading sedentary lives. The loss of hair may be produced either 
rapidly, or, more commonly, slowly, and at any period after the puberal 
epoch. It is always symmetrical and at times remediless, partial cal- 
vities being the permanent result of the process. The pilary growth 
may recede gradually and evenly from the forehead, or, what is more 
frequent, recede from the temples on either side of the median line, 
leaving a more vigorous crop extending centrally toward the root of 
the nose, or produce the effect of the tonsure described above. In many 
families there is a predisposition to this premature loss of hair, usually 
in the form of the receding temple, that may be recognized in the males 
of succeeding generations. 

The process may begin with slight thinning of the hairs in the 
affected regions as the result of loss of the pilary filaments, but on 
close examination it becomes clear that the hairs which remain are 
relatively lustreless, and lacking both in vigor and in size as compared 
with the hairs growing on unaffected portions of the scalp. Often the 
fall of individual hairs is followed by a new growth of younger fila- 
ments, these rarely developing beyond the grade of short and slender hairs 
which either soon disappear or persist without much further develop- 
ment. It is noticeable that the ensuing loss (usually very gradual, 
occasionally rapid as a consequence of the changes in the bodily health) 
may be associated with the growth of strong and actively growing hairs 
over unaffected regions (occiput, bearded face, pubes, etc.). In some 
persons the baldness, even before the attainment of the middle of the 
third decade, involves the greater part of the scalp. 

The obvious causes are assigned different weight by different authors, 
inherited tendencies playing an important part. In-door occupations, 
such as are the lot of the professional classes, counting-room workers, 
etc., and the wearing of stiff hats which operate not merely by exclu- 
sion of sunlight and air, but also by constriction of the scalp about the 
temples, are largely responsible for the result. The claim that daily 
application of water to the scalp is a cause of baldness is ill-founded. 
Many individuals who have indulged regularly in the practice for 
years have exhibited a luxuriant growth of hair on the scalp even in 
old age; and the animals not aquatic, whose education or instincts 
have led to very frequent immersion of the skin in water are not known 
to suffer from induced alopecia, though it is well known some of the 



ALOPECIA. 573 

domesticated animals suffer largely from alopecia due to other causes 
(errors in diet, artificial habits as respects housing, etc.). 

Symptomatic Presenile Alopecia may result from a number of 
systemic and local conditions. Loss of hair (Defluvium Capillorum) 
is commom after typhoid, eruptive, and other fevers, and after other 
local and systemic disorders interfering with the nutrition of the scalp. 
Frequently the hairs do not fall for some weeks after the patient has 
recovered from the constitutional disturbance, but remain in their fol- 
licles until pushed out by the new hairs, or until gradually pulled out 
by the use of brush and comb. In these cases there is usually a gen- 
eral and symmetrical thinning of the hair. The loss is not often per- 
manent, as new hair gradually replaces that which has fallen. The 
alopecia of the early periods of syphilis is of this order, but occurs in 
characteristic patches. A slower loss of hair is seen in many cachectic 
conditions such as tuberculosis, diabetes, leprosy (in which the alopecia 
is limited often to the eyebrows and eyelids), and myxoedema. 

Alopecia Furfuracea (Pityriasis Capitis, Alopecia Pityrodes 
Capillitii). — Of all the local causes of alopecia, seborrhoea in some 
form is the most frequent. 1 Loss of hair varying from moderate thin- 
ning of the growth to considerable symmetrical baldness, usually of the 
vertex, accompanies the pityriasic forms of seborrhoea or eczema sebor- 
rheicum of the scalp. The affection is exceedingly common, especially 
in men. 

The disorder, essentially chronic in course, may be gradual or 
relatively rapid of occurrence. Usually it is manifested first in 
early adult life, though persons of both sexes, from twelve to fifteen 
years of age, may at these ages display typical forms of the disease. 
After the condition known as Dandruff lias existed for some months 
or years the subject of the affection discovers a relatively large loss of 
hair from the scalp, producing thinness of the growth upon the vertex, 
near the brow, or over the temples. The hairs, when examined in situ 
upon the scalp, are shortened, dry, harsh, lustreless, and rarely well 
anointed with sebum. They are rebellious to comb and brush, and 
project irregularly from the brushed surface. Those shed from the 
scalp, especially of men, are found to be nearer in type to the lanugo- 
or downy hairs than those which fall physiologically from a vigorous 
growth of hair in a healthy subject; that is, they are short, thin, 
pointed, and often with an indistinct medulla. 

At the same time the scalp is in process of incessant desquamation, 
the scales usually being of pityriasic type, and exceedingly abundant 
so long as the alopecia is not complete, after which the epidermal catarrh 
soon disappears. The mealy, bran-like scales are shed in a fine shower 
upon the clothing of the patient, and, the disease being more common 
in men than in women, its traces are often distinct upon the collar of 
the coat after the fingers have been passed through the hair. The 
same flour-like, whitish and grayish scales are distinct and plentiful 
among the hairs to which they cling, and they can also be recognized 

1 Of 300 cases of premature alopecia, Jackson (Jour. Cutan. Dis., 1900, xviii., p. 
352) fouud 75 per cent, due to seborrhoea. Elliott (N. Y. Med. Jour., 1895, lxii., p. 
525) states that of 346 cases over 90 per cent, were due to this cause. 



574 ATROPHIES. 

over the scalp-surface when the latter is inspected with care. Itching 
is often marked ; the scalp may be scratched and torn by the nails, 
and is, in some cases, reddened and thickened. The condition is prone, 
sooner or later, to develop the severer phases of seborrhoea and eczema 
seborrheic um. 

Other local causes of alopecia are found in various inflammatory 
disorders of the scalp, such as psoriasis, eczema, etc. ; in morphoea, and 
lupus erythematosus ; in syphilitic, tubercular, and other destructive 
lesions ; in some forms of folliculitis (considered in the succeeding pages) 
in which the follicle and surrounding tissue are destroyed by suppura- 
tion ; in ringworm, favus, and other parasitic affections of the scalp ; 
in traumatism, which may occur as a bruise or be the result of 
scratching or rubbing ; after drug ingestion (thallium acetate) ; and 
after exposure to the x-rays. 

The forms of alopecia described above as encountered upon the scalp 
may involve also other hairy portions of the body, as of the axillae and 
the pubes ; and these also in variable degrees. 

Etiology and Pathology of the Alopecias in General. — The 

causes of congenital alopecia are not known. Senile alopecia is attrib- 
uted by many to the general atrophic changes which take place in the 
aged. This atrophy evidently will not explain the cases, often classed 
as senile alopecia, occurring in men under sixty or seventy who are 
in all other respects vigorous. The hair-loss in systemic conditions is 
due largely to defective innervation and nutrition of the scalp. 
Those due to trauma, to the presence of vegetable parasites, and to 
destructive agents of any sort, are explained readily. 

There remain a large number of cases of idiopathic alopecia the 
causes of which are obscure or differently interpreted by different 
observers. Those associated with seborrheal flux are explained by 
Unna on the basis of the morococcus recognized by him ; while Sa- 
bouraud assigns as the chief factor for many forms the seborrheal micro- 
bacillus discovered by him. Round and oval spores have also been 
described by Melassez (1874) as existing both in the hair-pouches and 
in the neighboring horny layers of the scalp. According to Sabour- 
and, the bacillus responsible for the result produces first an irritative 
effect in the horny layer of the skin with the result of forming a " coc- 
coon " agglutinated to one side of the pilary shaft. Then follow : 
sebaceous flux, hypertrophy of the sebaceous gland, atrophy of the 
hair-papilla ; and gradually thereafter pigment-failure, absence of 
medullary cells, thinning of the filament, its substitution by a dwarfed 
hair, and eventually calvities. 

The views of none of the observers and experimenters who have 
devoted an enormous amount of skill and energy to this work have 
achieved general acceptance. One of the chief objections to such 
acceptance rests upon the fact that the complete clinical picture of seb- 
orrheic and other forms of alopecia has never been reproduced artificially 
either upon man or animals. 

Treatment. — In symptomatic alopecias the underlying conditions, 
local or systemic, must be treated by measures appropriate to each case, 



ALOPECIA. 575 

The general health should always be considered, and any condition 
interfering with the nutrition of the scalp and hair should be removed 
as speedily as possible. Cod-liver oil, the ferruginous tonics, and the 
hypophosphites, are indicated in many cases. The distaste for fats 
shown by certain victims of alopecia furnishes an indication in their 
systematic management. 

The following general considerations are worthy of attention in 
many cases : Massage of the scalp, practised by the fingers once or 
twice daily in such a manner as to influence the subdermal struct- 
ures, is useful. A pillow filled with hair or other equally firm mate- 
rial, should be preferred to the feather pillows in common use, and in 
which the scalp is often too warmly and too deeply cushioned. In the 
case of women the wearing of artificial hair should be interdicted ; as 
well as the use of the " crimping-iron " and the curl-paper. Sharp 
hat- and hair-pins thrust deeply between the hairs are often a source 
of serious damage. In all patients the access of sunlight and fresh air 
is needful for the vigor of the hairs of the scalp. Disuse of the 
brush and preference for the comb in arranging the hairs on the 
head of women are responsible for the hair-loss in many instances. 
Every scalp from which the hairs are falling requires daily gentle, sys- 
tematic friction with a hair-brush the bristles of which penetrate to the 
scalp-surface and stimulate gently without wounding or irritating. 
Faradization and electricity being as a .rule less systematically avail- 
able, may be regarded as useful adjuvants in the hands of the expert. 
Singeing the hairs is without question harmful. The hat should be 
light, and well ventilated, and worn as little as possible. 

Local treatment is of importance in nearly all cases, and in general 
is directed toward stimulating the nutrition of the hair-follicle by pro- 
ducing in its periphery a species of transitory and artificial hypersemia. 
This result is accomplished by the local employment of one or more 
of the alcoholic, oily, alkaline, and other stimulating applications 
described below. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap, or combinations of glycerin, alcohol, and sapo viridis 
(tincture of green soap) to meet the requirements of individual cases. 
The shampooing may be practised every few days, once in the week, 
or once every two or three weeks, according to the needs of each case. 
The scalp after all such shampooings should be anointed with lanolin, 
plain or salicylated ; vaselin ; equal parts of lanolin, glycerin, and 
rose-water ; the oil of benue ; or scented castor-oil. In obstinate cases 
the nail-brush may be used vigorously over insensitive scalps at the 
time of shampooing. The ointment-bases named above may often be 
medicated advantageously with sulphur, resorcin, chrysarobin, tar, 
cantharides, or mercury. Instead of ointments, lotions containing 
cantharides, carbolic acid, capsicum, resorcin, mercuric chloride, am- 
monia, or nux vomica may be used. Great care should be taken to 
avoid unpleasant staining or dyeing of the hair by both resorcin and 
chrysarobin. The former should never be compounded with ammonia. 
Formulas for lotions and salves to be used in this way are appended ; 



576 



ATROPHIES. 



B 



R 



B 



B 



B 



B 



Hydrarg. chlorid. corros., 
Spts. vin. rectif., 
Acid. acet. dil., 
Glycerin., 
Aq. ros., 

Hydrarg. bichlorid., 
Tinct. cantharid., 
01. amygdal. dulc, 
Spts. rosmarin., 
Spts. vin. rect., 
Aq. destill., 

Sulphur, praecipit. 
Lanolin., 
Glycerin., 
Aq. rosse, 

Hydrarg. chlorid. mit., 
Hydrarg. amnion, chlor., 

Vaselin., 



Resorcin., 
Quinini (alkaloid), 
01. ricini, 
Alcohol., 



gr. v; 

5S ; 

^ss; 



60 

8 

15 

180 



33 



M. 



gr. nj ; 




3 s s; 


15 


S; 


4 


S; 


30 


Sy; 


60 


q. s. ad Svj ; 


q. s. ad 180 



20 



M. 



3j; 



aa 



4 
aa 10 



M. 



Biv; 

By; 



gr. xv ; 

TTL x-xxx ; 

ad |;iv; 



M. 



5 

2 
ad 30 
[Bronson.] 

41 
1 
2 60 

ad 1281 M. 

[Stelwagon. ] 

10 

1 

50 

ad 150 



M. 



Cantharid tinct., ^ij ; 

Capsici tinct, Til xv; 

Spts. vin. rect., gjss; 

Aq. ros., ad §v; 

The addition of acetic acid to a scalp-lotion seems to favor penetra- 
tion of other remedies. Pilocarpine hypodermatically has given good 
results. Further suggestions regarding the details of treatment of alo- 
pecia, and the special remedies recommended for alopecia furfuracea, 
are given under Seborrhoea sicca. 

Prognosis. — Congenital, senile, and many of the so-called presenile 
idiopathic alopecias are practically remediless, though in all forms 
further loss of hair often can be prevented or greatly retarded by 
proper treatment. The symptomatic alopecias in which there is de- 
struction of the hair-follicle, as in lupus erythematosus, syphilitic 
ulcers, favus, and some forms of folliculitis, are permanent ; those due 
to systemic disorders and to local inflammations are usually temporary. 
In alopecia furfuracea persistent treatment will prevent further loss of 
hair, and in recent cases may produce a new growth. 

ALOPECIA AREATA. 1 

(Lat. area, a vacant space [arere, to wither, Fox].) 

(Porrigo Decalvans, Tinea Decalvans, Area Celsi, Area 
Johnstoni, Alopecia Circumscripta. Fr., Pelade.) 

Alopecia areata is a disorder affecting the hairy surfaces of the 
body, often limited to the scalp but at times generalized, characterized 
at the outset by the occurrence of one or several, circumscribed, round 
1 For bibliography, see Dehu, La Pratique Dermatologique, vol. iii., p. 647. 



ALOPECIA. 



577 



or oval areas completely destitute of hair and exhibiting few if any 
other changes in the part affected. Crocker makes an etiological classi- 
fication of these cases, assigning to a first class the " universal " 
forms : to a second the local or neuritic forms : to a third the parasitic 
forms, " true alopecia acuta " : and to a fourth the circinate seborrheic 
forms. 

The hair-loss is limited usually to the scalp, but may occur upon the 
beard, the genitalia, axillae, brows, eyelids, and the general surface of 
the body. Cases occur, especially in early childhood, in which the 
closest scrutiny with a glass fails to detect a single filament of hair 
upon any portion of the skin. 

The disease commonly manifests itself by the sudden and complete 
loss of hair over a circinate, circumscribed patch, usually upon one side 
of the scalp, so rapidly effected that a first discovery of the fact may 
be made at the toilet of the morning. Occasionally vague neuritic sensa- 
tions precede the hair-loss. In yet other cases the loss of hair is 
gradual, the patch attaining large dimensions in the course of two or 





Fig. 63. 




' 


. j|fa ri 




I^Kp ■ 


m m- 




Hh 


:-:dM 





Alopecia areata. 

three weeks. Less frequently an area of baldness will continue to 
extend peripherally for many weeks. Instead of one area, there com- 
monly are several, which may develop simultaneously or at varying 
intervals. 

The patches may be round, oval, circinate, or irregularly shaped, 

and may vary in size from that of a small coin upward. They may 

be so numerous as to disfigure the entire scalp, and though they touch 

at the borders they can scarcely be said to coalesce, as the individual 

37 



578 ATROPHIES. 

areas are usually recognizable. Extension, however, may occur by 
coalescence of patches as well as by development of the area of a 
single patch. Their surface is smooth, soft, whitish, and usually 
destitute of hairs. The affected scalp may be thinner and more 
lax than normal, and often is depressed slightly below the level 
of the surrounding skin, but in rare instances it is tumid and slightly 
reddened. As a rule, there are no subjective sensations, though the 
affected areas may be the seat of slight pruritus, or of anaesthesia, and 
are nearly always less sensitive to irritating applications than the sur- 
rounding normal parts. 

The hairs at the periphery of patches that have attained their 
full development are normal in every way, and are firmly implanted in 
their follicles, but at the borders of areas which are still spreading the 
hairs are loose and fragile, often broken off near the surface, thus 
leaving short stumps which exhibit at the bulb a spade-like extremity 
or an attenuated point, the non-atrophied shaft thus contrasting with 
the wasted portion implanted below the cutaneous level. Crocker 
likens their shape to that of the exclamation-point. Newly formed 
areas may be covered in greater or less degree with these character- 
istic hairs, which, however, soon fall out. 

The course of the disease is variable ; it may persist for months or 
years without apparent change ; or new patches may form while those 
of an older date gradually regain wholly or in part the pilary growth 
which, however, may be lost repeatedly in the same area. Shifting 
areas of baldness may in this manner invade the entire surface of the 
scalp, which yet at any one moment of time exhibits a loss of but part 
of its hirsute covering. 

"When the filaments begin to reappear there is commonly a fine, 
downy growth over the affected area, later replaced by a crop of 
thicker and stronger whitish filaments, which are always succeeded, in 
cases terminating favorably, by a growth of hairs as well colored, as 
vigorous, and as persistent as any which were at first lost. An odd 
appearance is often presented by patients who are improving, when the 
young and white new hairs contrast vividly with the dark shade of 
those on the unaffected scalp. 

This disorder, which is more common than is generally believed by 
physicians, may, in some cases, at its outset be preceded or be accom- 
panied by symptoms of ill health, such as headache, malaise, inappe- 
tence, loss of flesh, or malnutrition. In other cases, cephalalgia, 
paresthesia, pruritus, and formication of the skin of the scalp and 
other regions indicate disturbance of the nervous centres. Often, how- 
ever, patients of this class are in sound health. 

Among the unusual features of the disease may be mentioned the 
occurrence of alopecia in bands or streaks ; at the site of an injury or 
along the course of a nerve ; or over the entire body, removing even- 
the finest lanugo-hairs. Universal alopecia may occur suddenly, or as 
the result of a gradual thinning of the hair, or may follow the exist- 
ence of the disease in characteristic areas. This variety of alopecia, 
which is fortunately rare, usually occurs after the middle period of 
life, but it may develop in the very young. 



ALOPECIA. 579 

Odd-looking effects are produced when in the course of the disease 
with and without the development of patches in the scalp, the half of 
a moustache on one side of the face falls, or the hairs of one eyebrow 
or one eyelid : or even when all the hairs are lost from both brows and 
lids of each side of the face. 

In some instances alopecia areata is associated with other cutaneous 
diseases. It is not rare to discover patches which are also the seat 
of the vegetable parasites. A male patient, long psoriatic, under our 
observation exhibited a typical seborrhoea capitis, and later developed 
a no less typical alopecia areata. Cases associated with vitiligo are 
reported by Besnier, Duhring, Freeland, DuCastel, and others. Coin- 
cident dystrophy of the nails has been observed by Darier and Le 
Sourd, 1 Crocker, G. H. Fox, 2 and others. Other conditions reported 
as associated with alopecia areata are, scleroderma, thyroid disease, and 
moniliform hair (Walsh). 3 

The course of the disease in young subjects is usually toward a favor- 
able result. There is hope, as a rule, when even the downiest and 
thinnest growth, requiring a good light and a glass for its recognition, 
can be appreciated. Even when so feebly attached that these filaments 
are removed with ease by the fingers or a brush, and when they spon- 
taneously fall they may be replaced by crop succeeding crop of 
stronger filaments, which eventually persist. In serious cases, usually 
after the forty-fifth year of life, and in those of long standing, there 
may result atrophy of the hair-follicles and a resulting remediless 
baldness. 

There is reason for believing that the disease has a stadium of 
evolution and involution, though its exact limits are not known. 
Few individuals fully recover the hair in less than one year. The 
majority attain the desired end within a period of two years. These 
limitations, however, apply to the asymmetrical forms of the disease 
in the relatively young. The symmetrical alopecia areata of the 
middle-aged is a far more formidable affection, though in many of 
these cases, when the loss is recent, proper treatment will restore the 
hair. 

Few diseases are the source of greater mental distress than those of 
the class under consideration. The prominent deformity debars the 
subject of the malady from social relations of many kinds, and this 
intensifies the morbid feeling which every reflected view of the head 
awakens. This fact is particularly true of women. The successful 
management of these cases calls often for the supporting assurances 
of the practitioner. 

Alopecia Circumscripta seu Orbicularis is a rare form de- 
scribed by Neumann in which the areas are much depressed, are the 
size of a pea or smaller, and are decidedly anaesthetic. The prognosis 
is unfavorable. 

Etiology. — In their modern acceptation, the words alopecia areata 
describe merely a loss of hair occurring at first in restricted areas 

p. 10 
Brit. Med. Jour., 1902, i., pp. 812, 883. 



580 ATROPHIES. 

which may become generalized and which without question may spring 
from various causes. The conflicting views of the nature of the dis- 
ease have been concerned with the etiological factors supposed to be 
responsible for the results, and have demonstrated the fact of their 
multiplicity. It is unwise to-day to describe one form as " true " and 
another as spurious, simply on the ground of diversity of causes. 
Equally unfounded is an arrangement of the several clinical appear- 
ances into different forms of the disease because of a difference in 
their etiological relations. 

The neuropathic origin of a large number of cases (Alopecia Neu- 
rotica) is indisputable and verified in every clinical experience. Blows 
on the head, not rarely resulting in well-marked scars visible on careful 
inspection of the affected regions, nervous shock (fright, lightning- 
stroke, great and prolonged anxiety, grief), traumatism of other regions 
than the scalp-surface, prolonged and severe toil in close apartments, 
these again and again have produced typical clinical symptoms of the 
disease. Max Joseph 1 produced baldness in the ears of cats and rabbits 
by excision of the second cervical ganglion. Jacquet 2 finds that alo- 
pecia areata is associated frequently with defective teeth or other sources 
of irritation of the cutaneous nerves. The coexistence of well-marked 
alopecia areata with changes in the nails, with the symptoms of Graves' 
disease, and in particular in young women with cessation of the men- 
strual flux which is restored when the bald areas became covered with 
hair, all point to the nervous origin of many cases. Crocker states 
that 90 per cent, of all cases with complete denudation of an affected 
area are due to parasitic disease, but this ratio certainly does not hold 
good for even the average of patients seen in America. 

The coexistence, possibly with etiological relations, of alopecia areata 
and other affections of the invaded surface is noteworthy. Vitiligo, 
ringworm of the scalp, syphilitic affections 3 of the same part, derma- 
titis, folliculitis, etc., have all preceded or existed at the same time with 
the disease under consideration. 

The parasite described by Sabouraud and those recognized by other 
observers have been claimed to be the effective cause of the disease, 
and this view is supported for a special class of cases by the evidence 
furnished where several instances of the disease have occurred in one 
family and in particular by the prevalence of so-called " epidemics " of 
the disease in public institutions, such as have been reported in this 
country by Bowen 4 and Putnam, 5 and also in France, Germany, and 
elsewhere. It is to be noted, however, that few of the cases reported 
as occurring in epidemic form have been illustrations of the disease in 
typical manifestations. In yet other instances in which there are good 
clinical evidences of contagion, it is impossible to deny that a strong 
case is made out in favor of the parasitic origin of the malady and the 
possibility of its extension by transmission of a germ from one indi- 

1 Monatshefte, 1886, v., p. 483. 

2 Annales, 1902, s. 4, iii., p. 97 ; see also Tremoliers, Presse me*d., 1902, liv., p. 576. 

3 See Morrow's Case, Jour. Cutan. Dis., 1902, xx., p. 275. 
* Jour. Cutan. Dis., 1899, xvii., p. 400. 

5 Arch, of Peediat., 1892, ix., p. 595. 



ALOPECIA. 581 

vidua! to another. No classical reproduction, however, of alopecia 
areata has yet resulted from infection of the sound skin with pure 
cultures of any of the parasites claimed as effective. 

Alopecia areata occurs with equal proportion in the two sexes, rather 
more often in persons having dark than in those of light hair, and 
among these irrespective of social condition. Of the partial and asym- 
metrical forms, the larger number occur in young subjects, from child- 
hood to early adult life. The severe and generalized forms are encount- 
ered more often in middle-aged persons. In the latter class especially 
the disease is observed occasionally to follow the obscure disorders of 
the nervous centres due to sudden or prolonged undue excitation. In 
young subjects a peculiar repugnance to the ingestion of fat and meat 
may often be discovered. 

Pathology. — The anatomical lesions in alopecia areata have not 
been determined definitely. The hairs fallen from the surface, when 
examined with the microscope, are seen to be atrophied in bulb and 
shaft, as in other forms of alopecia. Fracture of the shaft is in some 
cases also noted, evidently an accident of the process. 

As a result of careful examination of many pathological sections, 
Giovannini l and Robinson 2 believe the disease is primarily an inflam- 
mation of circumscribed areas of the corium, and especially of the sub- 
papillary layer. In a small patch of one week's duration Robinson 
found marked perivascular cell-infiltration in a limited region of the 
corium, the papillae being but mildly affected, while the epithelium, 
rete, subcutaneous tissue, and glands were normal. Some of the hair- 
follicles were normal, while in others no papillae could be found, and 
the hairs were wanting or imperfect. In cases of longer standing 
evidences of inflammation were more marked and extensive, and there 
were vessels with thickened walls and narrowed lumina. In some 
cases there was more or less atrophy of all elements of the corium, 
with destruction of the hair-follicles and sebaceous glands. Giovan- 
nini, who describes an invasion by leucocytes of the hair-follicle, con- 
siders the process a deep-seated folliculitis. 

Eichhorst, 3 Thin, 4 v. Schlen, 5 Robinson, 6 Bowen, and others dis- 
covered in affected patches and about the bulbs of hairs in alopecia 
areata micro-organisms which were cultivated in generations, but which 
were not shown to be effective in the production of the disease de novo. 
In a series of three hundred cases Sabouraud 7 found in the early stages 
of the disease a micro-bacillus. He obtained pure cultures, with which 
he produced typical areas in calves, rabbits, and guinea-pigs. He 
finds the same bacillus in comedo, acne, and seborrhcea, and believes 
that alopecia areata is an acute form of seborrhcea oleosa. Walker and 
Rockwell 8 found that in the majority of 63 cases examined by them, 

1 Annales, 1891, s. 3, ii., p. 921. 
* Morrow's System, iii., p. 865. 

3 Virchow's Archiv, 1899, lxxviii., p. 197. 

4 Trans. Royal Soc, 1881-82, xxxiii., p. 247. 

5 Virchow's Archiv, 1885, xciv., p. 327. 

6 Morrow's System, iii., p. 862. 

7 Annales, 1896. s. 3, vii., p. 253. 

8 Scottish Med. and Surg. Jour., 1901, viii., p. 12. 



582 ATROPHIES. 

the hairs were sheathed with staphylococcus epidermidis albus (Welch) 
and there was coexistent seborrhcea. 

Sabouraud finds constantly in the early stages large numbers of 
his micro-bacillus surrounded by keratinized epithelium, forming a 
cocoon-shaped mass which occupied the much dilated follicle-neck. 
In the later stages of the disease he finds no bacilli, but describes 
inflammatory changes, atrophy of the follicle, and achromia of the 
basal layer, all of which he ascribes to the influence of local toxins. 

Diagnosis. — Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments, moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm and favus of the scalp the disease in question is 
differentiated by the suddenness of its onset ; the absence of stumps 
of hairs, scales, crusts, and evidences of irritation in the involved area ; 
the whiteness, smoothness, and complete baldness of the latter ; and, 
above all, by the failure to detect with the microscope the evidence of 
the presence of a vegetable parasite. Ringworm and alopecia areata 
may coexist. In cases of so-called " bald-ringworm " the diagnosis 
must rest upon the microscopical findings. 

The asymmetrical patches of seborrhcea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the scalp-sur- 
face, as well as by the slow and very gradual onset of the disorder. 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those result- 
ing from traumatic injuries of the scalp with cicatricial results, are 
easily determined as having such an origin. 

Treatment. — One necessarily views with distrust all treatment 
for that disease which in the course of months or years usually termi- 
nates in spontaneous recovery, and in the meantime may bid defiance 
to each and every therapeutic measure. Nevertheless, persistent and 
hopeful management of even apparently desperate cases is occasion- 
ally rewarded by such brilliant consequences that, however slight may 
be the foundation for a belief in the value of the therapy employed, 
it deserves recognition and trial. 

The hygienic management of every case is a matter of importance. 
The general condition of the nervous system should be considered and 
may call for changes in the habits of working, eating, resting, and 
exercising. Tobacco in every form should be denied to subjects of the 
disease. Iron, quinine, nux vomica, cod-liver oil, phosphorus and the 
hypophosphites, arsenic, and strychnine are often indicated, and used 
with great benefit. Crocker advocates the administration of the nitrate 
of pilocarpine \ to \ grain (0.008-0.01) at night, a flannel night-dress 
being worn subsequently. Pilocarpine by hypodermatic injections into 
the scalp in doses of from -^ to -^ grain (0.001 5-0.006) is also praised. 

There are few patients who are not benefited by daily salt-and-water 
bathing of the entire body-surface, followed by brisk friction, espe- 
cially over the spinal region. In the case of children this treatment 
must be conducted by a skilled hand. When practicable the cold 
douche is to be preferred. 



ALOPECIA. 583 

In all cases in which the scalp is involved in either sex, and in 
which the special hypochondriasis of the disease is developed, a wig 
should be worn for the sake of its moral effect upon the sufferer. Its 
use, however, should be limited to social occasions, visits, etc., as the 
persistent wearing of a peruke indoors seems to lengthen the course of 
the disease. 

The indications for local treatment are to prevent transmission 
of the disease to unaffected persons by the precautionary measures 
useful in restricting the spread of ringworm and favus of the scalp, to 
destroy any parasites that may be present, and to increase the physio- 
logical afflux of blood to the hair-follicles. With this end in view 
the affected parts are to be bathed daily in water as hot as can be 
tolerated, then dried, and rubbed with a stimulating lotion. After 
the lotion dries it is well to apply an oil or simple ointment. The 
articles usually employed are alcohol, ether, resorcin, formalin, tur- 
pentine, ammonia, camphor, cantharides, carbolic acid, oil of mace, 
croton-oil, tincture of nux vomica, tincture of capsicum, tincture of 
aconite, castor-oil, tar, iodine, sulphur, and the mercurials. All fre- 
quently fail. Several of these substances in combination seem at times 
to be of service. 

The following is a formula, the ingredients of which may be varied 
to suit the indications in different cases. 

R 



M. 



01. ricini, 


f^ss; 


15 


Acid, carbolic, 


3j; 


4 


Cantharid. tinct., 


Sss; 


15 


01. rosmarin., 


gtt. xv ; 


1 


Spts. vin. rectif., 


ad f^iv; 


ad 120 



Sig. For external use over the scalp with friction. 



The preparations containing sulphur, resorcin, pyrogallol, and chry- 
sophanic acid (which have the disadvantage of staining the hair), mer- 
curic chloride, etc., given on a preceding page in connection with the 
treatment of seborrhoea capitis, are often valuable. 

Formalin in solutions of 0.5 to 2 per cent, is sometimes efficient. 
It should be used with care, however, as it has occasioned severe der- 
matitis, and in several instances has given light hair a green color. 

Jackson recommends liquor ammoniaa fortior, applied once or twice 
daily to the bald areas. Speedy return of hair in a patch of alopecia 
areata has followed the application of pure creosote and also of tri- 
kresol to the denuded surface, resulting in moderate vesication. The 
spirit of turpentine and pure carbolic and acetic acids have similarly 
been employed ; but caustic applications are to be used with caution, 
and over limited areas at a sitting. 

By many experts, having in mind the probability of a parasitic 
origin, epilation is practised to the extent of removing all the loosened 
hairs and a narrow zone of sound hairs about each patch. By others, 
shaving of the patches is substituted for epilation. The remedies 
selected for application are of the order of parasiticides ; for example, 
mercurials, sulphur and its compounds, chrysarobin, pyrogallol, and 
iodine. 



584 ATROPHIES. 

Repeated blisterings of the scalp with cantharidal collodion, croton- 
oil, spirit of green soap, and petroleum have also been employed with 
success. The ointment of chrysarobin has the disadvantage of staining 
not only the remaining hairs, but often also the face in consequence of 
the frequency of a transmission to that locality through the medium of 
the hands. When patients, however, consent to the use of chrysarobin 
it is worthy of trial, as its application has been followed by a vigorous 
growth of new pilary filaments. Hodara 1 states that the application 
of a 30 per cent, preparation of chrysarobin for from two to eight weeks 
is followed by vascular and inflammatory changes which lead, through 
proliferation of prickle-cells and connective-tissue cells, to the forma- 
tion of new follicles, new sebaceous glands, new papillae, and new hairs. 
Andre employed ten hypodermatic injections of pilocarpine muriate in 
\ grain (0.008) doses, which resulted, in the case of a middle-aged 
woman affected with total symmetrical baldness, in an abundant growth 
of hair. . Mercuric chloride has similarly been employed. 

Phototherapy has been used by Finsen, Forchammer, Jersild, 
Leredde, Torok, Schmidt, and others, including ourselves, in alopecia 
areata with, on the whole, very favorable results. 2 For circumscribed 
areas the light-treatment gives better results apparently than are ob- 
tained by other methods, though it fails in some instances. It has 
been used successfully where a number of large areas were present, but 
in such cases the treatment is tedious, and, as a rule, does not give such 
good results. Of eleven cases treated by us, seven made excellent 
progress, while four did no better than with ordinary methods. In 
two cases the disease was limited to a single area of three to four 
months' duration. In both instances three treatments of twenty min- 
utes each, during a period of two weeks, were followed by a complete 
return of the hair. In a third case of eighteen months 7 duration, with 
eight or ten areas, four twenty-minute applications to each area during 
a period of three months were followed by a normal growth of hair. 
Though it will be necessary to try the treatment in a much larger 
number of cases before its value in so erratic a disease as alopecia areata 
can be judged properly, the results so far obtained are encouraging, and 
are in keeping with the fact that distinct hypertrichosis can be observed 
upon the arms of nurses which have been exposed much to the light. 

Faradization of the scalp with a stiff wire-brush, pushed to the 
point of producing moderate hyperemia, has been followed by excel- 
lent results. Holzknecht 3 has employed the arrays in one case with 
a favorable result. 

Wilson recommends : 

R 01. amygd. dale, fgjj 30 

8 



01. amygd. dale, 


m 


Capsici tinct., 


f3y; 


Liq. ammon. fort., 


!l j; 


Spts. rosmarin., 


f^v; 


01. limon., 


f3j; 



30 

150 

4 



M. 



1 Jour. Mai. cutan., 1903, xv., p. 644. 

2 For bibliography, see paper by one of us (Montgomery), Jour. Cutan. Dis., 1903, 
xxi. p. 529. 

' 3 Wien. klin. Kundschau, 1901 (abstr. in Brit. Jour. Derm., 1902, xiv., p. 35). 



ALOPECIA. 585 

Another stimulating application is : 

R 01. terebinth., ) iiafSss- aa 15 

01. ricini, } aal^ss, aa ID 

Origani tinct., f 3j ; 4 

01. campborat. , f ^j ; 30 

Liniment, volatil., ad fliij; ad 90 M. 

Sig. For external use with a brush until the scalp is irritated. 

Shaving should regularly be practised when in men the region of 
the beard is involved, as the deformity is thus rendered less conspicu- 
ous ; and the bald surface should be stimulated frequently with one or 
several of the topical applications named above. Alcoholic solutions of 
resorcin (3 to 20 per cent.) or of mercuric chloride, \ to 1 grain (0.033- 
0.066) to the ounce (30.), are to be well rubbed over the patch or patches 
once or twice daily. 

Prognosis. — From what precedes, it will be inferred that, as re- 
gards the relief of the baldness, the asymmetrical development of alo- 
pecia areata in youth is much more favorable than the symmetrical 
general disease of middle life, the latter being often remediless. In 
all cases the practitioner should actively persevere to the end. In no 
case should any encouragement be given as to complete relief within 
the year, though exceptionally short careers of the disease are observed 
at times. The prognosis of the same affection of the beard is quite 
favorable, the disease, in young men, usually concluding its stadium in 
the course of about one year, with a favorable termination. 

ALOPECIA FOLLICULARIS. 

(Folliculitis Decalvans, Lupoid Sycosis, Ulerythema Sycosi- 
forme, Alopecia Cicatrisata. Ft., Folliculite epilante, 
folliculite et perifolliculite destructif du follicule 
pileux, Folliculite et Perifolliculite decalvantes, 
Alopecie cicatricielle innominee, Acne decalvante.) 

A series of closely related yet differing forms of folliculitis and 
perifolliculitis may involve the hair-follicle and its adjacent parts, de- 
stroying not merely the hair-bulb, but also the hair-papilla. As a 
result these conditions are followed by permanent alopecia and by the 
production of scars. The inflammatory nature of the process is usu- 
ally though not always apparent. There is commonly a marked 
tendency to grouping of lesions, but they may be scattered and iso- 
lated. These disorders, studied with special care by French observers, 
are yet but imperfectly understood, and none is perfectly distinguished 
from the other dermatoses resulting in hair-loss. 

The following types of disorders, many of them of great rarity, 
some observed by but few experts, are recognized by Brocq : 

(a) Cicatricial alopecias in small irregularly disseminated plaques. 
These can be recognized when any scalp that has been the seat of a 
severe alopecia pityrodes is minutely studied. They are probably 
accidental results of that morbid condition, and are due to infection of 
the follicles with cocci. 



586 ATROPHIES. 

(b) Cicatricial alopecias of the scalp, the eyebrows, and the face, 
in which minute glistening whitish points result, compared by Brocq to 
the lesions produced by destruction of the hair-papilla in electrolysis. 
It is possible that these lesions are due to the cause suggested for the 
first group. 

(c) False alopecia areata (" pseudo-pelade " of French writers). In 
these cases the scalp about one or several hair-follicles becomes tumid 
and reddened. The hair is loosened in its pouch, and, whether it fall 
spontaneously or be removed by epilation, it is not replaced by another. 
The scalp is left whitish, smooth, ivory -like, depressed, thinned, insensi- 
tive, and apparently atrophied, without trace of the new-formed downy 
hairs often noticed in alopecia areata. As distinguished from the last- 
named disorder, the advance of the patch may be in irregular lines 
rather than by extension of the rounded or oval circles formed in alo- 
pecia areata. Minute islets of bald areas exhibit the outlying evidences 
of disease. 

(d) Cicatricial alopecias with a punctiform appearance of the plaque. 
Here there is an inflammatory involvement of the follicle and peri- 
follicular tissue, with redness of this special region that disappears after 
atrophy has occurred. The sequel is a depressed whitish cicatriform 
tissue, marked here and there with pinhead-sized, reddish points where 
the circumpilary exudation is still in activity. 

(e) Quinquaud's Disease 1 (Acne* D6calvante of Pailler and Robert). 
Here miliary abscesses, punctiform, pinhead-sized and larger, involve 
the follicle. The hair originally piercing these suppurative lesions is 
loosened and falls, after which the follicle atrophies and the hair is no 
longer produced. The scalp is left dead-white, thinned, depressed, 
atrophied, and cicatriform, in patches as large as those visible in alopecia 
areata, but often irregular in outline. The follicles remain distinct and 
are not fused into a mass ; they resemble the distribution of the lesions 
in coccogenous sycosis. In some instances this special follicular alopecia 
and scarring have progressed without suppurative involvement of the 
follicle, and in cases without any signs of inflammation. 

(/) Lupoid sycosis (Brocq) ; Ulerythema sycosiforme (Unna). 
Special attention should be directed to this affection, as it is of great 
importance to distinguish it from the more common variety of cocco- 
genous sycosis, which it strongly resembles. 

This disease chiefly affects the male beard (a region more accessible 
than the scalp to the fingers), and its early symptoms are well-nigh 
indistinguishable from those of sycosis of the type named above. 
There are large and small, well-defined, follicular and perifollicular 
pustules, with redness, infiltration of the derma, scales, crusts, and 
characteristic deformity; but as the disease progresses the hairs are 
removed from the whole or a large part of the involved area, and there 
is left, after a relatively long period, occasionally suddenly produced, 
a cicatricial or keloid-like surface, which may be smooth or highly 
irregular. 

In mild cases there is left a reticulum of narrow, scar-like, whitish 
lines, irregularly radiating over the surface, giving to the eye and touch 
1 Bull, de la Soc. med. des H6p., 1888, s. 3, v., p. 395. 



ALOPECIA. 5S7 

the suggestion that they are depressed below the general level of equally 
irregular areas of the bearded chin or cheek. These areas may or may 
not be provided with hairs ; in the former event the growth is stunted 
by the contracture of the encircling atrophy, where a species of fibrosis 
has occurred. 

In severer cases there is left a more generalized cicatriform tissue, 
for the most part unprovided with hairy filaments. The process may 
be such as to interfere with the movements of the lips in articulation 
and mastication. These parts, for months after the disease has accom- 
plished its evolution, are somewhat reddened. In both forms the cen- 
trifugal direction of the morbid process has been observed. 

(g) In a last group are placed a few ill-defined cicatricial alopecias, 
beginning often with perifollicular, rather than follicular, pustulation, 
accompanied by redness of the affected part and the eventual formation 
of peculiarly persistent crusts. When these crusts fall a reddish, 
slightly scaly surface is left, followed by cicatricial atrophy and a patch 
with distorted and friable or fairly vigorous hairs, surrounded by an 
elevated rim. There is little definition ; distinct patches of the disease 
are rarely seen. It more often affects the beard, and may be symmet- 
rical. It may coexist in the same subject with acne-keloid, atrophic 
acne, and other varieties of that disorder, with w T hich it is unquestionably 
related. 

The several members of this group of rare affections of the hairy 
regions of the body have not yet been distinguished satisfactorily the 
one from the other, and indeed the entire group from other well-known 
affections of the pilary system. The general characters observed in all 
are : alopecia in limited areas, rarely extensive in the region of the 
scalp, preceded or not by the development of pinhead-sized papules 
or pustules obviously seated about the pilary follicles, or simple redness 
of the latter with slight elevation of the orifice of the hair-pouch. The 
circumscribed patches of alopecia resulting are seldom larger than a 
small coin. Often they are much smaller, and the surface may be 
scaly, crusted, depressed, glistening, or checkered w T ith islets and wisps 
of starved hairs, the follicular pouches of which rise above the level 
normal, or depressed, of the involved patch. The subjective sensations 
are slight ; the disease is slow in its course ; the resulting alopecia is 
often remediless. Occasionally there is a pinkish-red border to the 
involved area. 

In the form described as " lupoid sycosis " the deformity may be 
very great, the bearded region seamed with ridges and scars, the fol- 
licular orifices, when not atrophied, presenting a vivid violaceous red 
tinge, the surface being involved symmetrically and completely. 

Etiology and Pathology. — There can be no question that some 
of the cases designated in the group of affections outlined above are 
instances of lupus erythematosus of the scalp. Some of them exhibit 
the border, the color, the thickening, and the characteristic stippling 
of patches of that disease. Until lupus erythematosus of the scalp 
has been studied exhaustively, its existence in this region, when there 
are no facial or other lesions to indicate its character, will scarcely fail 
to be misunderstood. 



588 ATROPHIES. 

Other cases unquestionably are of the order of acnitis and acne 
necrotica limited to the scalp. We have found tubercle-bacilli in 
classical instances of Unna's ulerythema sycosiforme (lupoid sycosis). 

The patients are usually male subjects in the third decade of life. 
Younger and much older patients, however, have been observed. 

Sections of tissue reveal merely the results of inflammation with 
starving by compression of the pilo-sebaceous conduit as a result of 
the encompassing cell-infiltration. 

Fig. 64. 




Lupoid sycosis. 

Treatment. — The internal and local treatment is practically that of 
alopecia already detailed. Clipping, epilation, the application of para- 
siticides, and the remedies advocated in alopecia seborrheica are often 
useful. Sulphur, resorcin, the mercurials, salicylic acid, and iodine 
all have been employed with success. Corrosive sublimate lotions, 1 
in 400, boric acid lotions and powders are useful. Galvano-cauteri- 
zation of the pustules and inflammatory points has been employed 
successfully in some of the reported cases. All these disorders are 
well managed if treated in accordance with the principles suggested in 
the section on Sycosis. 

We have had brilliant results in the management of obstinate lupoid 
sycosis by the #-rays (see Sycosis). 

Prognosis. — The disease is often severe, obstinate, deforming, and 
rebellious to treatment. The prognosis of the lupoid sycosis type prom- 
ises to be improved greatly by the employment of radiotherapy. The 
resulting alopecia in most forms is remediless. 



KELOID-ACNE. 589 

KELOID-ACNE. 1 

(Sycosis Nitchje Necrotisans, Sycosis Frambcesiformis, Der- 
matitis Papillaris Capillitii. Fr., Acne keloldienne, 
Pian ruboide [Alibert], Sycosis papillomateux ; Ger. y 
Nackenkeloid.) 

Under this title Kaposi 2 describes a disorder characterized by pinhead- 
sized, isolated or confluent elevations of the skin-surface, with inter- 
spersed pustules, which finally form cicatriform plaques over which the 
hairs are either clustered in tufts or are totally absent. The pilary 
filaments are atrophied yet firmly fixed in their follicles, and they 
suffer elongation or fracture before withdrawal. The disease is encoun- 
tered chiefly upon the nucha, the occiput, and the vertex. Papil- 
lomatous vegetations, crust-covered, hemorrhagic, and with a foul- 
smelling secretion, sometimes form, and eventually retract into a scle- 
rotic tissue. 

One of us has described typical cases of this disorder, 3 each of which 
concluded with the production of a keloid-like, cicatriform, irregularly 
shaped but circumscribed elevation of the surface. This feature is that 
by which it specially differs from all other sycosiform disorders. The 
disease seems to be due fully as much to inflammatory processes in the 
subcutaneous tissue between the unyielding pericranium and the thick 
scalp as in the derma proper, and therefore it is not, strictly speaking, 
a dermatitis. Puncture, for example, of one of the pinhead-sized 
pustules commonly gives exit to the usual quantity of pus ; but pressure 
upon the scalp in the periphery will at once be followed by the appear- 
ance of a still larger quantity of similar pus which evidently is expressed 
from a circumscribed subcutaneous abscess. When by such pressure 
the abscess-cavity is emptied it slowly fills with venous blood and 
produces a firm, semisolid elevation of the surface that subsequently 
undergoes sclerosis, and the starved hairs above behave in the manner 
described by Kaposi. The papules and plaques are formed in a sim- 
ilar way by the abundant supply of venous blood. The case of one 
of the patients presented at the clinic had been erroneously diagnosti- 
cated by a surgeon as aneurismal in character. Puncture of all such 
semisolid, cicatriform lesions is invariably followed by oozing of venous 
blood in abundance. The disease is chronic in character, is particu- 
larly liable to relapse in crops of pilary or peripilary pustules and 
papules, and it extends from nucha to vertex, avoiding the frontal and 
temporal regions. Over the bald or partially bald keloid-like eleva- 
tions there is seen, in some cases, a species of seborrhoea in the form 
of more or less adherent, fatty crusts, with occasional characteristic 
tufts of hairs. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 

1 For a survey of the literature, with clinical and histopathological report, see 
Porges, Archiv, 1900, lii., p. 323. 

2 Treatise, Wien, 1880. 

3 Jour. Cutan. Dis., 1882, i., p. 33. 



590 ATROPHIES. 

the venous supply of the scalp is not only greatest, but where it is also 
in most direct connection with the large vessels beneath, and where an 
inflammatory process in the derma or subcutaneous tissues invites with 
readiness a pathological afflux of blood. Such a focus, limited beneath 
by the dense calvarium, and above by the relatively thick scalp, 
readily undergoes organization and sclerosis, the subsequent behavior 
of the hairs and hair-follicles being an accident of the process. 

According to Besnier and Doyon, the disorder is a papillomatous 
development, likely to occur in this region of the scalp as a sequel of 
epilating, cicatricial (keloid) acne, eczema, or traumatism. 

Sangster (in a paper read before the International Medical Congress 
in London, 1881) described a pigeon 's-egg-sized tumor of the scalp, 
that Kaposi, who was present, recognized as a case of dermatitis papil- 
laris capillitii. Crocker describes in detail a similar case, an occipital 
lesion measuring three and one-half by two and one-half inches. 

Treatment. — The therapy of this rare disease can scarcely be 
described as established. Internal treatment is suggested by the con- 
stitutional condition of the patient, and it should often include cod-liver 
oil, the ferruginous tonics, and a roborant regimen. The affected 
surfaces are freed first from subcutaneous abscesses by puncture and 
expression of the contents. Then the patch is washed with hot car- 
bolized water, dusted with boric acid or iodoform, and a compress, 
moistened with an antiseptic solution, such as corrosive-sublimate wash, 
is bandaged firmly over the part. When pathological fluids no longer 
form under the scalp the patch is best epilated and anointed with a 
salve containing 1 drachm (4.) of precipitated sulphur to the ounce (30.) 
of scented vaselin, which salve may also be kept constantly over the 
part. When crusts form they may be removed by shampooing with 
green soap. Other methods of local treatment advised are : electrolysis, 
linear scarification, erasion, excision, and electro-cauterization. 

The favorable results obtained with the arrays in acne and in keloid 
suggest the use of radiotherapy in keloid-acne. We have used the 
method in two cases, succeeding in both instances in arresting the 
active process and in causing a partial disappearance of the disfiguring 
scars. 

ULERYTHEMA OPHRYOGENES. 

(Gr. bvlri, scar; epvdq/ia, redness; typvg, brow.) 

This affection was described first by Taenzer 1 in Unna's clinic. 
According to Unna, it occurs most frequently in blonde infants, is 
located usually in the eyebrows, from which it may spread to adjacent 
parts, including the scalp, or it may appear on the extensor surfaces of 
the upper arms. The condition may be no more than a persistent 
erythema, with small, elevated, horny papules at the mouths of the 
hair-follicles. The hairs are finer than normal and usually are broken 
off close to the surface. The disease may persist for years without 
further change, but in the severer forms superficial inflammation, 
atrophy, both follicular and interfollicular, results, so that small de- 

1 Monatshefte, 1888, No. 5. 



ATROPHIA PILORUM PROPRIA. 591 

pressed scars are surrounded by, or commingled with, the hyperaemic 
areas. The resulting alopecia is permanent and may be very marked, 
especially on the eyebrows. 

The disease is said to be rebellious to treatment. Internally a fer- 
ruginous and arsenical treatment has been adopted with local applica- 
tions of resorcin, salicylic acid, the mercurials, and stimulating sham- 
pooings with soap. 

ATROPHIA PILORUM PROPRIA. 

(Atrophy of Hair.) 

Atrophy of the hair may be either symptomatic or idiopathic. Illus- 
trations of the first-named condition are observed in phthisis, syphilis, 
seborrhoea, parasitic affections of the scalp, and in almost all general 

Fig. 65. 




Congenital atrophy of hair. 

diseases interfering with the nutrition of the pilary growth. The fila- 
ments then become dry, lustreless, friable in both longitudinal and 
transverse diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the hair. 
One of these forms exists in those long hairs which are seen to be ir- 
regularly thinned or flattened in the shaft, and split at the point into 
two or more recurving fibrillar, a condition noted, for the most part, in 
few hairs scattered among those of full development and vigor. This 
especially localized atrophy seems to be peculiar to one or more follicles 
merely; and is analogous to the condition in which there appears 
among the vigorous pigmented hairs of early life a single blanched 
filament. 



592 ATROPHIES. 

FRAGILITAS CRINIUM. 1 

Under this title a number of disorders, due to atrophy, and pro- 
ducing fragility, splitting, or curling in abnormal directions of pilary 
filaments, have been described by authors. 

"Undescribed Form of Atrophy of the Hair of the Beard " 
of Duhring. 2 In this affection, either at the bulb or at a variable dis- 
tance from it but within the follicle, there is fission of the hair-fila- 
ments into from two to four stalks with coincident atrophy of the bulb 
itself, and consequent irritation of the surface. Duhring's patient ex- 
hibited to a marked degree the species of hypochondriasis to which the 
subjects of disease of the hair seem specially prone. This disorder is 
not induced by a parasite. 

In 1887 a gentleman applied to us for advice who was in a fair 
condition of general health, but the hairs of whose beard exhibited 
the symptoms described and figured by Duhring. Photo-micrographs 
of specimens of these hairs show clearly that in every case the fission 
of the filament extended completely to the base of the follicle and pro- 
duced there irritation. The hairs over several square inches of surface 
were thus uniformly affected, normal filaments being in such areas 
absent. The interfollicular spaces, however, seemed to be abnormally 
widened, as though in these areas such normal hairs might have fallen 
in consequence of a species of alopecia. The disease was much more 
strongly marked on the chin than on the cheeks or the upper lip. The 
curling of some of the splinters was complete and characteristic. In 
Parker's 3 case there were similar features. 

When the fission exists solely at the free ends or in the shaft of the 
hair, the morbid condition is obviously different from that described 
above. Several, many, or all of the hairs may be affected, the split- 
ting extending only a short distance from the point of the filament, or 
many inches beyond. The splitting of the shaft of long hairs in women 
without involvement of the point is due most commonly to the thrust- 
ing of sharp-pointed hair-pins through the hair-coils on the scalp, a 
single thrnst being thus capable of wounding a large number of hairs 
in a single braid. 

The Treatment of these conditions is primarily hygienic as regards 
both the general health of the patient and the preservation of the hair 
from artificial methods of management (hot ironing, curling, singeing, 
crimping, and wounding with hair-pins). 

Locally, stimulation with shampooings, and inunction with bland 
oils, and simple remedies are useful. The region of the beard when 
affected should be shaved regularly. 

1 See Jackson, Diseases of the Hair and Scalp, New York, 1890, and Jour. Cutan. 
Dis., 1903, xxi., p. 473. 

2 Amer. Jour. Med. Sci., 1878, lxxvi., p. 88. 

3 Brit. Med. Jour., 1888, h\, p. 1335. 



TRICHORRHEXIS NODOSA. 



593 



TRICHORRHEXIS NODOSA. 

(Trichopttlosis [Devergie], Nodositas Crinum, Trichoclasia, 

Clastothrix.) 

Trichorrhexis nodosa is a disorder of the hairs, first described by 
Wilson in 1849, and since by Biegel, Wilks, Devergie, Shewell, Bulk- 
lev, and others. 

Fig. 66. 




Trichorrhexis nodosa. (After Schwimmer.) 

In this affection the hairs display nodose swellings along the shaft 
at irregular distances, the beard and moustache being most often the 

38 



594 ATROPHIES. 

seat of the disease, though rarely there is involvement also of the hairs 
of the scalp, the axillae, and the pubes. The hairs are brittle, and 
fracture usually occurs through the node, leaving a broom-like mass of 
projecting filaments, while the internodular portions of the shaft appear 
normal save for enlargement of the medulla (Fig. 61). 

A single pilary filament may exhibit several nodes, which often are 
recognized first when the fingers are passed by accident along the shaft 
of the hair. 

The fracture may be at right angles to the shaft, or be longitudinal 
(Jackson). The nodes are whitish or grayish in hue and remotely 
resemble the nits of pediculi. The fragility of the hair at the centre 
of the node seems to depend upon the tension and consequent fissure 
of the cortical layer, which is greatest at that point. The hair-bulbs 
are firmly adherent in their follicles. In a form of this disease com- 
mon among the women of Constantinople Hodara 1 discovered a 
bacillus, with pure cultures of which he produced the disease in a 
woman's hair. 

Etiology and Pathology. — The disease is more common in male 
subjects. Various explanations have been made of its special features, 
gas-formation in the hair and subsequent bursting (Beigel), impaired 
nutrition, mechanical injury, and to the presence of various micro- 
organisms which have been recognized by Raymond, 2 Markusfeld, and 
others in their cases. Neina, Jadassohn, Unna, Crocker, and others 
have been unable to demonstrate a pathogenic parasite in the diseased 
hairs. Ravenel and Crocker found that the bristles of tooth- and 
shaving-brushes used by the subjects of this disease also were the seat 
of node-like swellings, suggesting a parasitic origin of the disease ; 
but Barlow found the same conditions in brushes employed by indi- 
viduals not suffering from trichorrhexis nodosa. 

According to Brocq, trichorrhexis nodosa is not produced by spe- 
cific bacteria upon the shafts of the hair : though Spiegler 3 reports 
that when of occurrence upon the beard, bacilli and cocci, probably 
identical with those described by Hodara, are found in heaps, not 
merely on the shafts of the hairs, but in the walls and enclosed bulb of 
the hair-crypts. 

Treatment is not satisfactory, as a rule. Sabouraud highly recom- 
mends daily applications of the following : 



B Hydrarg. bichlorid., gr. iij ; 

Acid, tartaric, gr. viij ; 

Resorcin., gr. xv-xxx; 1.00 to 2 

^th°er !i *&*'' **> 



20 
40 

00 

00 M. 



Shaving has been followed in some of Kaposi's cases by good results ; 
while Roeser 4 advocates the local employment of dilute tincture of 
cantharides. 

1 Monatshefte, 1894, xix., p. 173. 
3 Annales, 1891, s. 3, ii., p. 568. 

3 Wien. med. Blatt., 1895, xviii., p. 599 

4 Annales, 1877-1878, s. 1, ix., p. 185. 



MONILETHRIX. 595 

MONILETHRIX. 

(Moniliform, Beaded Hairs; Pili Annul ati. Ger., Kingel- 
haaren ; Fr.j Aplasie moniliforme intermittente.) 

Monilethrix is a somewhat rare condition first observed by Smith 
(as described below), and since by numbers of others, including Luce, 
Anderson, Crocker, Lesser, and Behrend. 1 A patient affected with 
this disease was exhibited at the International Congress of Dermatology 
held in London in 1896. Like the forms of fragility described above, 
the hairs are peculiar in exhibiting along the shaft a succession of rings 
or nodes, between which are narrower portions of the shaft, of a color 
lighter than that of the pigmented nodular or annular portions. The 
result is a characteristic checkered appearance of the hairs, often asso- 
ciated with alopecia in varying grades. Fracture always occurs in the 
internodular part, the fractured extremity having a characteristic brush- 
like stump. These conditions are due to atrophic changes in the 
internodular parts, with better development in the pigmented and 
thicker portions of the shaft, the whole being due to nutritive changes 
which Virchow, Hallopeau, and others explain as due to a periodic 
aplasia of the hair-papilla. The obvious symptoms are clearly the 
result of a profound process, originating probably in the trophic 
nerves. 

Etiology and Pathology. — The disease may be either congenital 
or acquired, and may occur in several members of one family as well 
as in generations. Both sexes are attacked, infants as well as adults. 
The disease is at times an accompaniment of pilary keratosis ; we have 
found it in association with a seemingly characteristic twisting of the 
hairs of the head ; in one case the hairs were distinctly knotted. The 
disease is due possibly to a periodic aplasia ; in some of the acquired 
cases in women it is due solely to thrusting of sharp-pointed hair-pins 
through the dense coils of long hairs on the scalp, producing thus trau- 
matism of the filaments and resulting malnutrition. In yet other 
instances we have found these conditions associated with fibrillation of 
the free or cut end of the hairs. 

The Treatment is through general and local improvement of the 
nutrition. 

Nodose Swellings of the shafts of the hair. Smith, 2 of Dublin, 
first reported a case of this disorder. Photo-micrographs of some of 
the hairs from this patient exhibit no fragility at the nodes, which 
beginning near the scalp are displayed regularly along the shaft, the 
fracture being always internodular. The spherical swellings along the 
shaft are also pigmented in a brown hue, and these pigmented nodose 
swellings, contrasting with the non-pigmented color of the unaffected 
portions of the shaft, give the hairs a singularly " checkered " appear- 
ance. No parasite is discernible in any of the specimens. 

Expansions and Fissures of the Hairs. — Michelson, under 
this title, discusses the abnormalities of the pilary system, instances of 
which are cited above, and he concludes as to the most of them that 

1 For complete bibliography, see Gilchrist, Jour. Cutan. Dis., 1898, xvi., p. 157. 

2 Brit. Med. Jour., 1880, i., p. 654. 



596 ATROPHIES. 

they are not separate diseases, but are expressions of an abnormal dry- 
ness and brittleness of the hairs due to atrophy. Cases of broom-like 
Assuring and division of the shaft into larger longitudinal splinters he 
regards as equivalent processes, both beginning by a cuticular loss and 
often merging into each other. 

This view may be sound with regard to a number of these rare affec- 
tions ; but even a superficial examination of the longitudinal splinters 
shown in Duhring's and the authors' cases reveals the fact that the 
shaft represented by the sum of all its splinters is greater than that 
of the average hair in diameter and circumference. Even the naked 
eye can recognize this fact. The distention of the epilating-forceps in 
seizing a single hair, in the case of our patient, was equivalent to the 
grasping of as many sound filaments as are represented by splinters. 

The therapy of these cases is not well determined. Michelson be- 
lieves shaving to be useless, and he recommends systematic shampoo- 
ing and oiling. Arsenic internally is worth trying in all cases in 
which it is not contraindicated. 

LEPOTHRIX. 

(Gr. TiSTtig, scale; dpi!-, hair.) 

(Trichomycosis Nodosa, Trichomycosis Palmellina.) 

This disorder, first described in 1869 by Paxton, and since recog- 
nized by Patteson, Pick, Babes, Barthelemy, and others, affects 
the hairs, chiefly of the axillae and the genital regions. The fila- 
ments are dry, brittle, roughened, and loosened in their follicles. 
Under the microscope the shaft is seen to be either for a great part or for 
the entire length ensheathed in a concretion which may here and there 
be interrupted by furrows — a diffuse form of the affection.^ In a 
nodose form there are irregularly placed spherical masses, isolated 
from one another and more numerous toward the point than near the 
implanted extremity of the shaft. Crocker describes also circular and 
well-defined masses, lying upon but not surrounding the shaft, three 
times the diameter of the shaft, and containing fibres of the cortex 
that had been split by the concretion. The fracture may be clean 
or be brush-shaped. The nodular masses are firm, gluey, well attached 
to the shaft, and reddish brown to blackish in shade. At times red- 
dish sweat of the axillae, due to micrococci, has been a coincident 
symptom. 

The nodes are found to be made up of chains of spherical or of 
elliptical micrococci, which penetrate the cortical layers of the hair 
with ease in regions of considerable moisture and sweat. The micro- 
organisms at first obtain access by minute separations of the cuticle of 
the hair, and they eventually penetrate more deeply, breaking up the 
cortical portions. While thus multiplying, a homogeneous substance, 
similar to the chitine by which the louse fastens its eggs to the hair, 
forms the bulk of the concretion in which the colonies of cocci are 
lodged. 

The Treatment is by shaving and external applications of mercuric 
chloride (1 ; 2000). 



P1EDRA. 59' 



PIEDRA. 1 

(Sp., piedra, a stone.) 

(Fr., Teichomycose Nodulaire.) 

Piedra is a name given to a disorder affecting chiefly the natives of 
certain districts in Colombia, South America. Both men and women, 
more frequently the latter, and persons of all races, are liable to con- 
tract the disease, which involves the shaft of the hairs of the scalp 
chiefly, but also the head and other hairy regions. The individual 
filaments are dotted at irregularly disposed points with minute nodosi- 
ties, apparently as hard as stone, from which circumstance the disease 
has acquired its Spanish name. The nodes are pinhead-sized and 
gritty, so small at times as to be scarcely perceptible to the eye, though 
distinctly recognized on palpation. A score or more have been found 
on a single hair sixty centimetres in length. The affected filaments 
are distorted, and apt to be matted and twisted, as in plica. Each node 
is fastened to the hair like a sheath, though it may be implanted on one 
side only ; is divided readily with a sharp knife and is colored in 
various shades of gray, brown, or black. AVhen a comb is passed 
through the hairs a distinct crepitation is produced by friction against 
the dense, nit-like nodes. 

The disease has been observed in a few instances in Europe, and 
once by ourselves in the case of a young girl in whom the eyelashes 
of both lids on each side w r ere dotted with numerous jet-black, horny, 
and dense spherical masses, firmly attached to the filaments. 

Etiology and Pathology. — According to Juhel-Renoy, the nodes 
are composed of numerous spore-like bodies, recognized readily by 
soaking the hairs in dilute liquor potassse after washing in ether. The 
spores are twice the size of those furnished by the trichophytons, are 
polyhedral as a result of counterpressure, and form a species of tessel- 
lated mosaic, the elements of which are united by a greenish soluble 
cement, in which are incorporated minute rods resembling bacteria. 

Other views advanced are that the disease is allied more or less to 
Biegel and Fox's " chignon fungus," that several varieties of fungus 
may be responsible for the concretions, and that the origin of the node- 
like masses is due primarily to a species of mucilaginous oil employed 
by the natives of Colombia for a hair-dressing. 

Diagnosis. — The disease is not to be confounded with trichorrhexis 
nodosa (though Scheube distinctly affirms that the two are identical), an 
affection in which the hair-shaft is involved, nor with lepothrix (tricho- 
mycosis nodosa), occasionally recognized on the hairs of the axillary and 
pubic regions, nor yet with monilethrix (q. v.), a still rarer affection of 
the hairs of the scalp. 

Treatment. — The disease is relieved readily by soap and water ablu- 
tions and by the employment of parasiticides. 

1 Manson, Tropical Diseases, p. 636. Morris, London Pathological Society's Trans- 
actions, 1879, p. 441 (with plate), and Medical Times and Gazette, 1879. Juhel- 
Eenoy, Annales, 1888, s. 2, ix., p. 77, and 1890, s. 3, i., p. 766 (with illustrations). 
Trachsler, Monatshefte, 1896, xxii., p. 1. 



598 ATROPHIES. 

CHIGNON FUNGUS. 
(Beigei/s Disease.) 

This affection is discovered upon false hairs, which exhibit on their 
shafts dirty-brownish nodes, due to masses of parasites. The fungus 
has not definitely been distinguished. The nodes are strung irregularly 
along the shaft of the hair. 

TINEA NODOSA. 

(Piedra Nostras.) 

This disorder, first discovered by Morris and Cheadle, 1 and since 
reported by Crocker 2 and Thin, 3 affects the hairs of the beard or the 
moustache. Nodular concretions are developed irregularly along the 
hair-shaft, the bulb remaining unaffected. Under the microscope the 
growth was recognized as an ensheathing mass which when the hairs 
were split penetrated below the cutis. It was seen to be made up of 
fungus-spores smaller than those of tinea trichophytina. The hairs are 
brittle and break or split. 

The Treatment is by shaving or clipping, with the application of 
parasiticides. 

ATROPHIA UNGUIS. 4 

(Fr., Onychatrophia.) 

Atrophy of the nails may be a congenital or an acquired condition, 
in which there is deficient or defective production of nail-substance. 
The congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the pilary 
growth. The nails may be absent in these cases, or merely be tardy 
of evolution ; occasionally they are seen, especially upon rudimentary 
or coalesced digits, in defective and distorted shapes. 

Nicolle and Halipre 5 and C. J. White 6 report interesting cases of 
dystrophic disorders of the nails and hair extending through several 
generations of the same family. In the French cases the condition was 
seen in thirty-six individuals in six generations. One of those affected 
was an idiot, another a subject of hysteria, and another of feeble intel- 
lect. There were other evidences of a family tendency to mental and 
nervous deterioration. The hairs in the affected individuals were 
scanty, short, thin, light-colored, friable, and easily epilated. The 
most marked symptoms, however, were in the nails, which showed vari- 
ous grades of hypertrophy and atrophy, with periungual changes of an 
inflammatory type, due probably to injury or secondary infection. 

1 Lancet, 1879, i., p. 190. 

2 Diseases of the Skin, p. 1176 : 

3 Lancet, 1882, ii., p. 742. 

4 For general literature of nail diseases, see Onychauxis. 

5 Annales, 1895, s. 3, vi., p. 675. 

6 Jour. Cutan. Dis., 1896, xiv., p. 220. 



ATROPHIA UNGUIS. 599 

In acquired atrophy the nail may be changed either in color, bulk, 
elasticity, firmness, shape, or position. Thus, the nail may be ex- 
panded and thin, narrow and acuminate, friable, furrowed, laminated, 
ridged, or otherwise distorted. It may uniformly or partially be 
lustreless, or singularly striped, or even irregularly speckled. 

These changes in various combinations result chiefly from trauma- 
tism, such injuries, for example, as are common to the toes in the boot 
or shoe, and to the fingers when actively employed in the trades. 
Excessive heat and cold and constant maceration in chemical solutions 
(as among photographers, dyers, and druggists) often operate injuri- 
ously upon the nail-tissue. The inflammatory dermatoses, eczema, 
psoriasis, and the like are frequent causes of atrophy and dystrophy of 
the nail. All serious disturbances of systemic nutrition, as are inci- 
dent to prolonged fevers, surgical accidents, tuberculosis, ataxic con- 
ditions, etc., interfere visibly with the nutrition and development of 
the nail. Syphilitic changes in the nail are commonly due to gumma- 
tous involvement of the matrix. Severe ulceration of the matrix is 
often followed by atrophic or other distorted conditions of the nail- 
substance. 

The Treatment of these conditions is largely that of the disorders 
upon which they depend. The nails may often with advantage be 
scraped to a desired smoothness, well trimmed, shampooed vigorously 
with green soap, employing this also over the adjacent soft parts of 
the digit, soaked in unguents, and then protected by wax, leather stalls, 
etc., from injurious contacts. Arsenic internally is said to be useful in 
some affections of this kind. 

Leukopathia Unguium (Leukonychia Acheomia Unguium, 
Albugo, " White Spots." Fr., Decolomzation des Ongles). — 
This is a peculiar condition found in young and healthy subjects who 
exhibit a number of dead-white macules on one or several of the nails, 
usually of the fingers. Morison, of Baltimore, reported to the American 
Dermatological Association x a case illustrated with a portrait, in which 
linear striae, transverse to the long axis of the digit, appeared on the 
fingers. Since then we have observed a group of similar cases of the dis- 
ease, one the subject of a portrait in oil, in which this condition existed. 
In all our patients, young people of each sex, the fingers of the two 
hands were selected capriciously for exhibition of the peculiarity. The 
disease is not so rare as once was thought, and has been described since 
by a large number of observers. 2 It has been supposed that the presence 
of air in the nail-substance is responsible for the appearance. The 
affection is probably a trophoneurosis due to nutritional changes in the 
nail-matrix. 

1 Vierteljahr., 1888, xv, p. 3. 

2 For bibliography, see Stout, Med. News, 1894, lxiv., p. 212; Heidingsfeld, Jour. 
Cutan. Bis., 1900, xviii., p. 490 ; Heller, loc. cit. ; and Brauns, Archiv, 1903, lxvii., p. 63. 



600 ATROPHIES. 



ATROPHIA CUTIS. 

(Gr. a, privative, and rpo^, nutrition.) 

The skin and its appendages, in common with other organs of the 
body, may suffer from atrophy, either idiopathic or symptomatic in 
character, and general or partial in extent. It may result from either 
quantitative or qualitative retrogressive changes, losing thus its nor- 
mal dimensions, either from wasting of one or of all its normal elements, 
or from degenerative changes in the latter, or from their complete and 
final disappearance. These changes may be simultaneous. They are 
usually effected slowly, and the results are persistent. They are fre- 
quent concomitants of a long list of other pathological alterations; 
usually, however, the atrophy succeeds other morbid changes. 

ATROPHIA SENILIS. 1 

(Senile Atrophy of the Skin, Atrophoderma Senile.) 

This is the frequently recognized cutaneous degeneration peculiar to 
old age. The skin becomes colored in various shades of brown, either 
uniformly or in tolerably distinct pea- to bean-sized maculations over 
the face, the dorsum of the hands, the genitalia and the anus, and the 
lower extremities. 

The skin assumes a dull-yellowish hue, is seamed with furrows and 
wrinkles, is dry and inelastic, may desquamate slightly, and, losing 
the cushion of fat upon which it rested in earlier life, is either readily 
raised from the subcutaneous structures or depends from them in loose 
folds. The hairs on the affected areas may fall or may undergo regres- 
sive changes to the lanugo-type. Pea- to finger-nail-sized verruciform, 
dirty-yellowish accumulations of sebum and epidermis become visible, 
often in numbers on the face and elsewhere, softish and readily scraped 
from the surface or firmly adherent and scaly, or there may be small 
pendulous shrivelled pouches representing fibromata that have disap- 
peared. These epithelial growths, especially when irritated, are not 
infrequently the beginning of malignant epithelioma. Occasionally 
they are commingled with whitish and grayish maculations or pin- 
head-sized and larger telangiectases. 

In quantitative senile atrophy the pathological changes include a 
general thinning of both corium and epidermis, as a result of which 
their characteristic interdigitations largely disappear ; an increased 
pigmentation in the rete ; a shortening of the hair-follicles ; a dilatation 
of the sebaceous and coil-glands, the mouths of which often become 
blocked with epithelial detritus ; the obliteration of some vessels and 
the dilatation of others ; and the disappearance of the fat-cells from the 
meshes of the connective tissue. 

In degenerative atrophy there may be fatty, amyloid, vitreous, and 

other changes of one or of several elements of the skin. Neumann 

described a senile atrophy with a granular degeneration and a vitreous 

swelling of the connective-tissue fibres. Schmidt, Reizenstein, and 

1 For bibliography, see Himmel, Archiv, 1903, lxiv., p. 47. 



ATROPHIA CUTIS. 601 

Unna think these changes due to a peculiar arrangement of the elastic 
fibres and their partial degeneration into elacin, or, in combination 
with the collagen, into collastin and collascin (Unna). These 
changes in the elastic fibres are manifested through the peculiar stain- 
ing qualities of the latter, and in the light of modern technique are 
exceedingly interesting, as they occur not only in atrophy, but also in 
other cutaneous disorders. 

Senile atrophy cannot be remedied, but it may often be prevented 
or postponed by securing for the skin and for all the tissues of the 
body the best possible nutrition and hygiene, and by protecting the 
skin from exposure to cold and other harmful influences. The nutri- 
tion of the skin may often be improved by the proper use of bran- or 
salt-baths, massage, electricity, or inunctions of oil. Cod-liver oil or 
other fats may usually be added to the diet with advantage. Care 
must be taken to protect all warty and other epithelial growths from 
irritation, with a view to the prevention of malignant changes. (See 
also Keratosis Senilis.) 

ATROPHIA MACULOSA ET STRIATA. 1 

(Atrophic Spots, Atrophoderma Striatum et Maculatum. 
Fr.y Yeroetures.) 

These forms of cutaneous atrophy may conveniently be divided into 
the so-called idiopathic and the symptomatic. 

Partial Idiopathic Atrophy of the skin occurs most frequently in linear 
cicatriform, often parallel, striae or streaks (a centimetre or more in 
length) developed chiefly about the hips, buttocks, and upper portion of 
the thighs, in persons of both sexes of adult years. Less frequently these 
striae are observed upon the neck, the trunk, and the extremities. They 
are insidious of development, indelibly persistent, and appear as sensibly 
thinned, glistening, and often depressed lines or furrows, having a 
whitish hue, with an occasional blending of a very delicate purplish 
tint. They are usually multiple, and at times abundantly displayed, 
running in various curves, for the most part at angles with the long 
axis of the body. They occasion, as a rule, no subjective sensation. 

Much more rarely the atrophic areas occur in macular patches. 
The lesions are then fewer, more isolated, and are discovered more 
frequently upon the extremities, but also upon the trunk, varying in 
size from that of a coifee-bean to that of a chestnut. This form of 
atrophy often succeeds either an erythematous or a pigmented condi- 
tion, which very slowly changes until there is formed a dead-white, 
round or oval, often insensitive patch, more or less depressed, resem- 
bling coarsely a vaccine cicatrix. These areas usually show partial or 
complete alopecia. 

Fere* and Quemonne 2 have described two singular cases of the disease 
observed in Charcot's clinic. In one of these cases appeared minute, 
whitish, elongated cicatrices, about which there was a marked pigmen- 

1 For bibliography, see Heuss, Monatshefte, 1901, xxxii, pp. 1 and 53. 

2 Le Progres med., 1881, ix., p. 837. 



602 ATROPHIES. 

tation of the skin„ They were abundant in the lumbar region. In a 
second case brownish lines appeared over the breast of an unmarried 
woman, that gradually grew paler while others appeared over the skin 
of the throat. Those lines which were recent had a brownish or a 
bluish-red color ; others were of a dead- white hue ; some appeared over 
the lumbar region and the upper part of the buttocks ; but there was 
none over the belly, the groins, or the thighs. In both cases the regions 
attacked were those in which there was no suspicion that the vergetures 
resulted from overdistention of the skin. 

These lesions are to be distinguished from sequels of scleroderma, 
syphilis, and other diseases capable of leaving atrophic areas. A pre- 
vious history of such pathological conditions would usually be obtain- 
able. In the cases in which there is precedent telangiectasis, hyperemia, 
or marked pigmentation of the spot, the diagnosis, as several authors 
suggest, is attended with some difficulty. - 

Diffuse Idiopathic Atrophy of the skin (General Idiopathic Cu- 
taneous Atrophy, Atrophia Cutis Universalis, Progressive 
Idiopathic Atrophy) is usually of progressive type. In these cases 
the integument over large areas, such as that covering an entire limb 
or the trunk, becomes thin, flaccid, dry, scaly, unprovided with fat, 
and brownish or dead whitish in hue. Puncta, striae, and plaques, 
reddish blue or reddish brown or even purplish in color, are to be 
seen marbling the surface and occasionally leaving after disappearance 
a decided pigmentation. The process slowly advances over the regions 
affected. 

Bronson has recorded a very unusual and interesting case of this 
form of atrophy, with reference to the principal cases so far reported. 1 
Elliot, 2 Fordyce, 3 Krzysztalowicz, 4 and others have reported cases of 
symmetrical and extensive atrophy, in which the progressive change was 
preceded by the occurrence of a zone of capillary dilatation or cyanosis. 
Acrodermatitis Chronica Atrophicans. — Under this title 
Herxheimer and Hartman 5 describe twelve cases of their own, and 
tabulate fifteen other cases previously reported by Hallopeau, Kaposi, 
Pick, Jadassohn, and others. The disease begins with small crimson 
or purplish-red areas or nodules on the upper extremities. The lesions 
usually appear first on the hands or fingers and extend upward slowly, 
during the course of months or years, along the extensor aspects of the 
arms. The lesions suggest chilblains at first, but as they grow older 
the color deepens and the centre undergoes atrophy, and is covered by 
a thin, wrinkled integument, suggesting " crumpled cigarette-paper." 
The disease is chronic, lasting many years, and is exceedingly resistant 
to treatment. Subjective sensations are slight or absent. The causes 
of the disease are unknown. Histologically the early stages show dis- 
tinct evidence of inflammation, which is followed by atrophy and pig- 
mentation. 

1 Jour. Cutan. Dis., 1895, xiii., p. 1. 

2 Ibid., 1895, xiii., p. 152. 

3 Ibid., 1897, xv., p. 199, 1901, xix., p. 491, and 1904, xxii., p. 155 (with three clini- 
cal and four histological illustrations and bibliography). 

4 Monatshefte, 1901, xxxiii., pp. 369 and 574 (with bibliography). 

5 Archiv, 1902, lxi., pp. 57-255. See, also, case reported by Levan, Ibid., 1903, lxv., 
p. 247 ; and case of erythromelie by Klotz, Jour. Cutan. Dis., 1904, xxii., p. 170. 



GLOSSY SKIN. 603 

Partial Symptomatic Atrophy of the skin in its simplest form may 
result from traumatism (the persistent marks sometimes left on the 
skin, for example, by a lash with a whip, insufficient to wound the 
epidermis but capable of injuring the deeper elastic tissue) ; or from the 
slow pressure of tumors (ovarian, uterine, mesenteric, etc.), by which 
the skin is distended. The well-known results of the stretching of the 
skin in a first pregnancy conducted to term are linear atrophies, at first 
of a violet tint, and later of a dead-whitish hue, that are indistinguish- 
able, both clinically and pathologically, from idiopathic lesions of 
similar aspect. These atrophies are occasionally seen over the belly 
and thighs of male subjects with a protuberant abdomen ; more rarely 
in persons of extreme thinness. Small atrophic scars result frequently 
from the mechanical pressure of inflammatory and other infiltrations 
in lupus, syphilis, leprosy, and other diseases. Partial symptomatic 
atrophy, with degeneration of the cutaneous elements (fatty, larda- 
ceous, waxy, etc.), is a sequel common to a long list of cutaneous 
affections. 

Etiology and Pathology. — The causes of idiopathic atrophy are 
not known. It can scarcely be doubted that cases of scleroderma and 
syringomyelia have been at times included in the list of disorders de- 
scribed in this connection. It is considered generally a trophoneurosis, 
with possibly malnutrition as a predisposing cause. Elliot's and 
Fordyce's cases (noted above) would suggest an origin in some cir- 
culatory disturbance. 

The histological changes are those of simple atrophy of the tissues 
without degenerative changes. 

The causes of the symptomatic atrophies are obvious. Histological 
examination shows in some cases simple tearing and separation of 
elements, especially of the elastic fibres ; in others an atrophy of the 
corium and epidermis. Unna describes a pressure-atrophy, in which 
the elastic tissue is torn or displaced to the margins of the area, and 
an atrophy due to tension which differs from the preceding in that some 
small fibres of elastin still are visible together with other fibres that 
have undergone a degeneration into "elacin," in this respect resembling 
senile degeneration. 

The Treatment is prophylactic as in senile atrophy. 

GLOSSY SKIN. 

( Atrophoderma Neuritica.) 

The "glossy fingers" described by Sir James Paget, 1 Gull, Mitchell, 
and others, are tapering, smooth, hairless, unwrinkled, glossy, pink, 
and ruddy or blotched, as if with permanent chilblains. One or several 
fingers are affected. The condition is associated with neuralgia or 
nervous impairment indicated by abnormal sensations, as of heat or 
intense burning. There is usually, however, a precedent or subsequent 
neuralgic pain, with incurvation of the nails and at times a heaping 
up of epidermal masses beneath the free border of the nail. In conse- 
1 Med. Times and Gaz., 1864, i., p. 58. 



604 ATROPHIES. 

quence of retraction of the skin over the distal phalanges the terminal 
extremity of the digit appears thinned and drawn away from the nail- 
bed. 

The complications of this condition are changes in the sebaceous 
glands and the coil-glands, loss of hair over the phalanges, excoria- 
tions, and in severe cases ulceration. 

This disorder may be associated with grave systemic states, such as 
lepra, or with gout and rheumatism. It is marked clearly in some class- 
ical instances of severe palmar and plantar keratosis. It is found also in 
those in whom for any reason the circulation is feeble and there has been 
exposure of the extremities to severe cold. It has likewise been noted 
as the result of centric and peripheral changes in the nervous system. 
In some cases the cause is recognized as a neuritis ; in other cases it may 
more properly be classed with the trophoneuroses of the skin. The rela- 
tions of this and several symmetrical disorders of the hands and feet 
to the so-called " perforating ulcer of the foot," " asphyxia " of the 
extremities, "symmetrical gangrene" of the extremities, and so-called 
" dying of the fingers," all manifestly trophoneurotic affections (see the 
chapter on this subject), have not yet satisfactorily been established. 

Blanching Atrophy of the Skin. — This peculiar degeneration 
of the integument is characterized by an unnatural whiteness or pallor 
of the skin-surface, with considerable tension and tenuity of the epider- 
mis, usually limited to the extremities (the arms and palmar faces and 
the thighs and legs and plantar faces); moderate exfoliation occurs, 
and the latter, in connection with the tension to which the skin is 
subjected, is responsible for more or less painful subjective sensations. 
The disorder is chronic in its course, and it may originate in infancy. 

This condition is occasionally illustrated by persons affected with a 
sensori-motor paralysis of one limb, when the muscles waste and the 
fat-cells persist, multiply, or wholly disappear. The skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs, at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
other cases of trophic disturbance the skin shrivels and assumes, instead 
of a whitish, a yellowish or yellowish-gray tinge. 

MULTIPLE BENIGN TUMOR-LIKE NEW-GROWTHS OF THE SKIN. 

Under this title Schweninger and Buzzi * describe and figure lesions 
occurring chiefly on the back, but also on the arms and the chin of a 
married woman, twenty-nine years of age. These lesions were bean- 
to coin-sized, bluish-white and slate-tinted formations, with delicate 
telangiectases over the surface of some. By pressure most of them 
could be forced into a shallow pit in the underlying tissue, the tumor 
returning like a ventral hernia after removal of the pressure. The 
larger seemed to spring from the smaller lesions, and as they increased 
in age became flatter, less white, harder, and less compressible. They 
produced no subjective sensations and in no way interfered with the 
1 Internat. Atlas, 1890-1891, v. 



PLATE XVI. 





Malum Perforans Pedis, with Symmetrical Keratoma 
of the Palms and Soles. 



(From a water-color sketch. 



PERFORATING ULCER OF THE FOOT. 605 

general health of the patient. The vigorous treatment adopted seemed 
to have but little effect on the growths. 

Under the microscope sections of the excised skin showed that 
elastic fibres were in every instance wholly wanting in the affected 
portions, nor were there signs of remnants or of degeneration-products 
of these elements. It was assumed that there had been in each locality 
a retraction of the elastic tissue, and that the resulting disease was due 
to a disturbance of the static balance, the overgrowth developing until 
the equilibrium was established. A growth of new and young cells 
was visible about the adventitia of the vessels and most of the acces- 
sory organs of the skin. 

KRAUROSIS VULVJE. 

Breisky, 1 in Austria, and Heitzmann and others 2 in America, have 
described a condition of the vulva in women, affecting particularly the 
labia minora, the preputium clitoridis, and the vestibulum, in which 
there occurs a peculiar shrinking, shrivelling, or atrophic change. The 
labia minora in some cases wholly disappear, shallow furrows taking 
their place. The clitoris becomes hidden from view and may be rep- 
resented by a minute depression in the membrane. The integument 
covering this thinned or atrophied tissue is whitish, thickened, rough- 
ened, and dry, while the surrounding parts are glossy, reddish-gray 
or pallid in hue. In many cases the atrophic changes are preceded by 
a period of congestion and intense pruritus, burning, or hyperesthesia. 
These subjective sensations usually disappear in the later stages of the 
disease. Women of all ages, from nineteen to seventy, suffer from the 
disorder, irrespective of coitus and pregnancy. 

In one of our patients the resemblance was very striking to certain 
indolent epitheliomata of the penis, where a remarkable shrinking may 
at times be produced in consequence of metamorphosis of tissue. 

In other cases we have found the lesions coexist with well-marked 
scleroderma of the shoulders. The disease is rebellious to treatment. 
Curetting has been of some service. Radiotherapy should be tried in 
extreme cases. 

PERFORATING ULCER OF THE FOOT. 

(Malum Perforans Pedis. Ft., Mal Perforant du Pied.) 

This disorder, first named by Vesigne has been studied by Savory 
and Butlin, 3 Gasguel, 4 and others. The name is an unfortunate one, 
since many cases to be classed only in this category have neither ulcer- 
ative nor perforating symptoms. 

Symptoms. — The first symptom is a proliferating thickening of the 
epidermis like a corn, usually single, occasionally multiple, appearing 

1 Zeitschrift f. Heilkunde, 1895. 

2 Of. Baldy and Williams, Amer. Jour. Med. Sci., 1899, cxix., p. 528 (with a review 
of the literature). 

3 Med.-Chir. Trans., 1879, lx., p. 46. 

* These de Paris, July, 1890 ; a resume of ninety-one collected cases. 



606 ATROPHIES. 

over a point of pressure (first or fifth metatarsophalangeal or metacarpo- 
phalangeal joint, etc.). Inflammation and suppuration proceed 
beneath this thickening, spreading first to the soft parts of the sole 
and perhaps to the bone itself. Gradually a sinus forms, reaching from 
the side of the corn to the deeper parts involved. Meantime the skin 
in the neighborhood becomes greatly thickened, heaping itself especially 
about the sinus. The latter sometimes is surrounded by a mass of 
granulations. The ulcer which eventually forms is circular in outline, 
deep, and at times very destructive in its effects. 

Thus far the lesion might be supposed to be the result merely of a 
greatly irritated corn, but other phenomena exhibited in differing 
cases are quite inexplicable in this way. The nails are altered ; super- 
fluous hair grows on the dorsal surface of the foot and the skin of the 
involved extremity ; pigmentation, erythema, or eczema may occur ; 
and the parts may become affected with either anidrosis or hyperidrosis. 
The disease has been noted as the result of spinal injury, congelation, 
posterior spinal sclerosis, anaesthetic leprosy, alcoholic and diabetic 
neuritis, and, in animals, after section of the sciatic nerve, the etiolog- 
ical element in these diseases being degeneration of the nerve (except 
of the motor nerve) which supply the part. Among the concomitant 
symptoms ascribed to the same causes are anaesthesia, neuralgic and 
rheumatic pains, hyperidrosis, and coldness of the feet. 

In a group of cases of perforating ulcer of the foot there is gen- 
erally a symmetrical involvement of the entire sole or palm, either of 
both feet or of both hands and feet. The patients are often young 
adults. The palms when involved never exhibit the translucent, 
yellowish, wash-leather-like appearance of the same condition of the 
soles, but rather suggest the dry, scaly features of the palms in certain 
forms of erythematous eczema of these parts, but always without itch- 
ing, and with coincident plantar tylosis. The soles, however, present 
the typical appearance of callositas throughout the entire region, the 
callosity reaching somewhat upward over the heel, and in certain 
patients relatively sparing the instep. In some cases the nails are not 
involved. The feet are always as cold to the touch as in pernio. 

Pathology. — The disease is, without question, a trophoneurosis, and 
may be due to injury to a nerve-centre, as in tabes dorsalis ; to a nerve- 
trunk, as in syphilis or leprosy ; or to the terminal nerve. Of ninety- 
one cases collected by Gasguel, 1 there were in sixty-nine central and 
in eight peripheral nerve-lesions. Histological examination has shown 
destruction of the myelin and axis-cylinder of twigs of nerves supply- 
ing the affected parts. According to Savory and Butlin, the sensory 
and nutrient fibrils of the involved nerves degenerate in consequence 
of pressure exercised upon them, by increase of the endoneurium, the 
motor fibrils escaping owing to their large size and thicker medullary 
sheath, a view untenable for all cases. Thomasczewski 2 reports ten 
cases associated with tabes, leprosy, diabetes, or cerebral or spinal dis- 
ease, the location, characters, and course of the ulcers being practically 
the same in all the cases. He believes the ulcers are due to trophic 
changes in the tissues resulting from systemic disease, usually that of 

1 Loc. cit. 2 Munch, med. Wchnschrft,, 1902, xlix., pp. 779 and 840. 



MORVAN'S DISEASE. 607 

the central nervous system, though the local anaesthesia and pressure 
are undoubtedly etiological factors in some instances. 

Diagnosis. — The diagnosis is between Madura foot, tuberculosis, 
and simple callositas, a distinction readily established by the evident 
neurotic phenomena seen in perforating disease of the foot. 

Treatment. — By curetting away all diseased tissue and putting the 
foot completely at rest the ulcer may be made to heal, but it usually 
reappears when the patient again tries to walk. Amputation of the 
toe and joint affected avails little. It is not unusual even after ampu- 
tation of the foot for the disease to appear in the stump. A roborant 
treatment and mechanical devices to prevent the use of the foot are to 
be advised in most cases. 

The Prognosis is doubtful. 

MORVAN'S DISEASE. 

(Syringomyelia, Analgesic Paralysis with Whitlow. 
Fr.y Panaris Analgesique.) 

Morvan's disease is a paretic affection chiefly involving the upper 
extremities, accompanied by pain and producing a series of whitlows, 
affecting first one side of the body and then the other. 

Symptoms. — In this disorder the arm is commonly first involved, 
the approach of the disease being insidious and usually first noticed on 
account of the production of pain and some loss of nervous and mus- 
cular power. At times the first sign of involvement is the production 
of whitlows, which either early or late in every case are tolerably sure 
to appear. In other instances the disease first displays an analgesia 
similar to that occurring in some subjects of lepra, the attempt having 
been made to establish a relation between the two diseases. 1 In time 
atrophy of the interosseous muscles, of the flexors of the wrist, and of 
the tissues forming the thenar and hypothenar eminences may result. 
The integument of the affected limb has a bluish or empurpled look; 
it may be thinned or thickened, and the seat of fissures, vesicles, and 
bullae, as well as of the characteristic whitlows, which vary in number 
from two to four or six. Ulceration, extending as deeply as to the 
tendinous sheaths, may result, and, as a consequence of one or more of 
the changes described above, the phalanges may necrose and be sepa- 
rated from the hand. 

Trophic changes arise in connection with the disease, pointing for 
the most part to an origin in disturbances of the centric nervous system. 
Among these disturbances may be named: hyperidrosis ; diminution of, 
variability in, or complete absence of the reflexes; visual changes; con- 
tracture of the fingers ; and a general distortion of the hand. Scoliosis 
and arthritic complications have been recorded in a number of cases. 

The disease is usually protracted in its course, lasting in some cases 
for a quarter of a century. 

Etiology. — The affection may develop first in childhood and last 

1 Of. Zarabaco, Trans. First Internat. Leprosy Congress, Berlin, 1889 ; Dyer, New 
Orleans Med. and Surg. Jour., 1893, xxi., p. 81 ; and Calderone, Giorn. ital., 1901, vi. ? 
p. 756 (includes survey of the subject and bibliography). 



608 ATROPHIES. 

until middle life and longer, though more often it is first noticed after the 
occurrence of puberty. Women are much less often affected than men. 
Traumatism, malaria, and rheumatism have all been cited as possible 
causes of the disease. Its exact etiology is obscure. 

Pathology. — Neuritis and thickening of the neurilemma have been 
discovered in the nerves distributed to the affected parts; as also 
sclerosis of the posterior cornua and columns of the cord. The cavities 
recognized in the central canal, distended with fluid, are supposed to be 
due to absorption of gliomata. 

Diagnosis. — The recognition of a fully developed case of Morvan's 
disease is readily established by taking into consideration the paretic 
symptoms present, the whitlows, and the perversions of sensation, 
more particularly in appreciation of temperature-changes, pain, and 
contact with foreign bodies. Attention has already been directed to the 
striking resemblance between certain phenomena of anaesthetic lepra and 
those of both syringomyelia and Morvan's disease. With respect to 
the diagnostic difference between the two last-named affections, it is 
claimed that in most cases of syringomyelia the sense of touch remains 
unimpaired. The time, however, is probably not distant when the two 
will be recognized as slightly differing manifestations of the same 
morbid state. Scleroderma and glossy fingers are to be differentiated 
by the special peculiarities of each. 

Treatment is to be conducted on the general principles, surgical and 
medical, relied upon for meeting the indications of each case. In gen- 
eral the hygienic and dietetic management of the patient with a highly 
roborant regimen is conducive to recovery. Many of the subjects of 
the disease have been reported as relieved or even wholly cured. 

AINHUM. 1 

(From a Nagos term, meaning "to saw.") 

(Banko-kereude ; Sukha pokla ; Quigila.) 

This disease was described first by Clark in 1860, since which 
time the literature of the disease has increased annually. It is an 
affection of the colored races chiefly, especially of the negroes of the 
West African Coast, as also of the natives of the Soudan, of Algiers, 
Egypt, the Transvaal, and, next to Africa, of the inhabitants of Brazil, 
though it has been reported in Rio de Janeiro, Buenos Ayres, the 
Antilles, and British Guiana. A few cases have occurred in the South- 
ern States of America, and Herrick 2 reports a case in a negro who 
had lived for thirty years in Illinois. Though most of the patients 
have been negroes, it has been recognized in a few cases in white 
subjects. 

Symptoms. — Ainhum affects the smaller digits, chiefly the little 
toe, but also other toes and fingers, sometimes one or more of the 

1 For bibliography, see Manson, Tropical Diseases, p. 655 ; Scheube, Diseases of 
Warm Countries, p. 564; Hirsch, Handbuch der Hist.-Geog. Pathologie, 1886, iii., p. 
504 ; Moriera, Monatshefte, 1900, xxx., p. 361. 

2 Phila. Med. Jour., 1898, i., p. 246, 



AINHUM. 609 

digits of the same foot or of both feet being involved simultaneously 
or successively. The onset is by the development of a furrow or 
shallow groove on the plantar face of the toe or palmar aspect of 
the finger near the digito-plantar or digito-palmar web. This furrow 
gradually deepens and spreads in a circumlinear direction until the 
digit is girdled by a constricting and indurated ring in the form of 
a superficial depressed gutter. The segmented portion of the digit 
becomes swollen, in consequence of the constriction, to twice or sev- 
eral times its normal size ; and in time, usually in the course of two 
to ten years, the segmented part, at first resembling a small potato 
attached to a slender pedicle, drops from its original attachments. 
In this way a species of spontaneous bloodless amputation is effected. 
The nail of the member that is about to be detached by this process, 
usually turns outward, the digit being commonly laterally everted. 
The changes in the segmented part, both in the nail and the tissues 
of the phalanges, are those naturally arising from strangulation of 
the member. The disarticulation may be effected at the first, second, 
or third joint : or even in the continuity of the phalanx. There is 
little pain save such as is produced mechanically by the use of the foot 
or hand from which the digit depends. Occasionally ill-conditioned 
and foul-smelling ulcers develop. In rare cases ulceration persists in 
the site of the wound left after separation of the digit. 

In some instances trophic, vasomotor, and sensory changes, particu- 
larly of the limb where ainhum is progressing, are striking features of 
the case. The skin of the part may be pigmented, scaling, wrinkled, 
puckered, with wasted muscles, or covered with an unusual pilary 
growth, the tendon-reflexes obliterated, and sensibility decreased. 
Thickening and shortening of the foot, flattening of the plantar arch, 
and palmar and plantar keratoses may be conspicuous. We have seen 
three cases in white subjects (one in France) where there was coincident 
palmar and plantar keratosis obviously of the same character as that 
to be recognized in the dense sclerotic ring which was working the 
amputation of the digit. 

The disease progresses slowly ; relapses are rare ; the process in 
general ends with removal of the constricted member. 

Etiology. — The disease occurs more often in male subjects of the 
African race, and in adults ; but is recognized also in children, and 
quite rarely in the white races. The tying of a ligature with a view to 
self-mutilation about the small digits, and the wearing of rings on the 
same, have been cited in explanation of the phenomena of ainhum but 
are given little support. The disease has been attributed to lepra, 
scleroderma, and to a trophoneurosis originating in changes occurring 
in the nervous centres, trunks, or peripheral branches. In some in- 
stances the disease would seem to be hereditary as there are reports of 
families every member of which has suffered. In other instances sev- 
eral members of two generations of a single family have developed 
ainhum. 

Pathology. — The constricting ring is composed invariably of fibrous 
tissue, surmounted by a thickened epidermis. There is commonly an 
increase of the subcutaneous fatty tissue. The bones constricted un- 

39 



610 ATROPHIES. 

dergo a species of fibrosis with enlargement of the medullary spaces, 
often fat-filled. 

In Duhring's case the papillae were long and broad, the capillaries 
dilated and serpiginous : there were a small-cell infiltration of con- 
nective tissue ; thickening of the adventitia and media of the larger 
vessels ; dilatation of the lymphatics and other signs of " inflamma- 
tory oedema." Eyles emphasizes the epidermal changes as of chief 
importance, the enlargement of the horny layer, and formation of 
" nests " of cells in the interpapillary pegs. 

With the knowledge had to-day respecting scleroderma and its re- 
lations to other diseases, it can scarcely be doubted that ainhum is in 
some cases a scleroderma annulare, originating in the causes found 
effective in the ordinary types of scleroderma. Manson reports the 
case of a negro with scleroderma of an entire hide-bound and shrunken 
little toe with a well-marked ainhum of the little toe of the other foot : 
three of the vertebrae of the tail of a monkey dropping off in conse- 
quence of the same process. 

Diagnosis. — The disease is to be distinguished from lepra mutilans 
and from Raynaud's symmetrical gangrene by the well-known symp- 
toms of those disorders. The fall of the digits occasionally occurring 
in tabes and other affections of the nervous centres should not be 
forgotten. 

Treatment. — Incision of the constricting ring at an early period is 
said to relieve the disease. In most of the cases amputation is required 
or is effected by the natural progress of the disorder. 



CLASS VI. 
NEW-GROWTHS. 



CICATRIX. 

(Scar. Fr., Cicatrice ; Ger. y Narbe.) 

A cicatrix is a new-formation of the skin, replacing connective 
tissue which has been lost by traumatism, by ulceration, or by some 
other pathological process. Most cicatrices, as, for example, those 
following the ulcerations of syphilis, the operations of the surgeon, or 
the dermatitis produced by a severe burn, are reparative in character. 

They vary greatly in shape, size, color, and other features. They 
may be smooth, glossy, shining, scaling, dull whitish in color, or pink- 
ish from vascularization of the surface. They may be linear, fan- 
shaped, circular, corded, ridged, dotted, crateriform, or tumor-like. 
They may be raised above the skin, on a level with it, or depressed 
below it. They may be deeply attached to periosteum or to bone, or 
readily be movable over the panniculus adiposus. They are of deeper 
color when young, and increase in whiteness with age. They are 
unprovided, as a rule, with hairs, or with coil- or sebaceous glands. 

The most insignificant cicatrices are those resulting from clean, 
incised, and punctured wounds and lesions of similar grade. Certain 
peculiarities of cicatrices are seen in special disorders in which they are 
produced. Circular, oval, reniform, horseshoe-shaped, S-shaped, and 
figure-of-eight-shaped scars, thin and flexible, are characteristic of 
syphilis. The cicatrices of variola, zona, and ecthyma are slightly dif- 
ferent each from the other, though all are of small size and depressed. 
Those of tuberculosis and dermatitis calorica of severe grade are exceed- 
ingly irregular and often corded. 

Hypertrophy of cicatrices is the condition elsewhere described as 
keloid. Here there is a tumor-like development of the cicatrix, form- 
ing a ridge, button, knob, indurated fold, or puckered and irregularly 
circumscribed, whitish or reddish lesions. In certain individuals these 
lesions may follow almost every traumatism and destructive process to 
which the integument is liable. 

A case of cicatrix undergoing involution has been described by Dyce 
Duckworth, in a man (aged fifty) who suffered from rheumatic fever 
on two occasions, ten years before the date of report. This patient 
had pericarditis, and was blistered over the precordia. Nine months 
afterward lines of cicatricial growth began to form in the scar left by 
the blister, and they rapidly extended ; in two years' time they were 
still enlarging ; in seven years some subsidence was noticed, and, when 

611 



612 NEW-GROWTHS. 

exhibited ten years after their first formation, involution was markedly 
progressing. This case illustrates the frequent origin of scar-tissue, 
its common occurrence over the sternum, and the fact of the subsidence 
of the new-growth in the course of time. 1 

Keloid-like cicatrix of the cheeks following acne is far from uncom- 
mon. Its lesion is usually smoothed down in the process of time, after 
the disappearance of the sebaceous gland-disorder, until the deformity 
is lessened greatly, and often scarcely noticeable. Colloid degenera- 
tion occurring in scar-tissue and producing lesions which clinically 
resemble those of xanthoma is described by Juliusberg 2 and Duben- 
dorfer. 3 We have seen this condition twice — once in the scars of 
syphilis and once in those of tuberculosis. 

Etiology. — The formation of cicatrix is always preceded by destruc- 
tion of at least a portion of the papillary body of the corium. This 
loss of tissue may be due to various causes : trauma, burns, ulcers, 
atrophy caused by pressure of new-growths, etc. Hypertrophied 
cicatrix may result from slight but continued or frequently repeated 
irritation of a healing surface, the repair of which is thus greatly 
delayed, but it occurs chiefly in the form of cicatricial keloid. 

Pathology. — Histologically, scars are made up of connective-tissue 
bundles which interlace in all directions with great irregularity. In 
young scars the fibres are finer and the tissue is vascular, but as the 
scar grows older the fibres usually become coarser and contract and the 
vessels disappear. There is complete absence of hair-follicles, glands, 
and furrows of normal skin. The scar-tissue proper is covered with a 
very thin epidermis, and Heitzmann claims that shallow and irregular 
papillae are always present. Other observers report in scars an entire 
absence of both papillae and rete-pegs. 

Diagnosis. — The distinction between hypertrophied cicatrix and 
keloid is one chiefly of degree and needless from a practical point of 
view. Following the piercing of the lobule of the ear for the insertion 
of earrings, the lesion is distinguishable by pinching the part betAveen 
the fingers, when a globular-, pea- to cherry-sized mass will be felt 
firmly imbedded in the derma between the reflected folds of the integ- 
ument. Upon the face, after the occurrence of acne, keloid can be 
usually seen as a puckered ridge, often transverse in direction, occu- 
pying the region of the cheek. 

Treatment. — The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautions are 
observed. The treatment of pathological conditions likely to be fol- 
lowed by cicatrices is the treatment largely of the special disease in 
which such loss of tissue occurs, e. g., the ulcer left by a degener- 
ating syphilitic gumma of the skin. An irregular or disfiguring cicatrix 
may be excised if there be sufficient tissue to permit direct union 
on either side. Skin-grafting may be employed after excision of 
larger scars. Radiotherapy has given good results in some cases, pro- 

1 Brit. Med. Jour., 1881, ii., p. 597. 

2 Archiv, 1902, lxi., p. 175 (with bibliography of colloid degeneration, and of 
pseudoxanthoma) . 

3 Ibid., 1903, lxiv., p. 175. 



KELOID. 613 

ducing, through absorption of the tissue, a softer, thinner, and smoother 
scar than the original. Injections of thiosinamin have been success- 
ful in a few instances. Further details are given under treatment of 
keloid. 

KELOID. 1 

(Gr. xrtv, a crab's claw.) 

(Cheloid, Kelis. Fr. y Cheloide, Cancroide; Ger., Knollen- 

KREBS, ALIBERT'S KELOID.) 

Keloid is a neoplasm of the derma usually following trauma, devel- 
oping as one or multiple fibro-cellular elevations of the skiu, irregularly 
shaped, smooth or corrugated, whitish or reddish in hue, and resem- 
bling a thickened and hypertrophied cicatrix. 

The term keloid, first given to the disease by Alibert, should be 
restricted to it exclusively. The so-called " keloid " of Addison is 
known to-day more properly as scleroderma. 

Authors have described two varieties of this disease : the " true," 
" spontaneous," or idiopathic form; and the "false," "spurious," or 
cicatricial form, which develops in the scar produced by a previous 
traumatism. 

There is no anatomico-pathological separation between the two. 
Cases of so-called " spontaneous keloid " are instances of development 
of the growth in regions of pressure, contusion, traction, or slight 
traumatisms that have not been recognized, such as the wounds inflicted 
by mosquitoes. Reiss 2 reports a case in which more than two hundred 
small keloid growths appeared over the chest and flexor surfaces of the 
extremities of a healthy girl, twelve years of age, without preceding 
cutaneous lesions or traumatisms. 

Symptoms. — The new-formations of this disease are dense, gen- 
erally elastic nodules imbedded in the corium or projecting above 
the level of the skin and firmly attached to it. They are usually 
slow of evolution, and, having once attained full development and 
assumed one of the several shapes which they affect, often persist 
for a lifetime. These forms are whitish or reddish, globular or semi- 
globular nodules, buttons, or plaques, with roundish or ovoid outline ; 
linear elevated striae, bands, ridges resembling cords, ribbons, or tapes, 
in irregular outline and disposition ; or combinations of two or more 
of these figures. A common form over the sternum and in other situa- 
tions where the development of the growth in every direction is not 
impeded, is that of a larger central mass with two or more diminishing 
and declining prolongations bearing a remote resemblance to the body 
and claws of a crab. The lesions vary in size from that of a smail 
pea to that of a large plate, the largest including the outlying points 
of the limbs or radiating ridges. Over them the skin is reddish or 
whitish in color, smooth, hairless, and occasionally hypersensitive to 
pressure and heat. Often blood-vessels traverse its surface. The 
growth at times is also the seat of spontaneous pain. 

1 For review of subject, with bibliography, see Eeiss, Archiv, 1901, lvi., p. 323; 
Berliner, Monatshefte, 1902, xxxiv., p. 321 ; and Tschlenow, Zeitschrift, 1903, x., p. 120. 

2 Loc. cit. 



614 



NEW-GROWTHS. 



The most frequent site of the disease is the anterior surface of the 
chest, but it is observed also upon the face, neck, ears, breast, hands, 
between the scapulas, and on the extremities (Fig. 67). Keloid is also 
seen upon the penis of the negro. It is far more common in the colored 
than in the white races. Though frequently multiple, there are rarely 
more than a score of these growths visible at one time upon the skin 
of one person. 

The overlying integument at times may wholly be uncolored in 
the white races, and dead whitish in color or even blackish among 
negroes. At other times the surface is not merely pinkish or red- 
dish, but is vividly red in hue. The color is produced by vascular 
connective tissue covering the growth. The subjective sensations 

Fig. 67. 




Keloid. 



aroused are commonly trifling or inappreciable ; at other times the 
growths are the seat of severe pain or of burning. The usual course 
of the disease is toward the production of tumors of a medium size, 
after which few changes are to be recognized. Involution and complete 
disappearance are rare. These results, however, have been secured in a 
few cases. 



KELOID. 615 

Cicatricial Keloid (Scar-keloid, Hypertrophic Scar, 
Hypertrophic Cicatrix) is a term employed to denote that the 
lesion has been preceded by scar-formation, due either to disease or to 
injury. It thus follows the lesions of zoster, variola, and syphilis, as 
also traumatisms of all sorts, including those made by surgical opera- 
tions and accidents. The tumors, as a rule, spring directly from scar- 
tissue, and after reaching a maximum of development do not surpass 
the limits of the original lesions ; at times, however, the growths slowly 
develop at a distance from the original site of injury or disease. Scar- 
keloid often is found as a firm nodule in the lobe of each ear among 
women, after piercing the ears for the insertion of earrings ; it is seen 
also not rarely as a result of burns, whether produced by application 
of caustic agents or of heat. 

Lesions of this kind rarely develop symmetrically. They may be 
counted at times by the hundred ; commonly but one or two are seen 
in one person. They may persist after reaching a maximum develop- 
ment, or spontaneously, wholly or in part, disappear ; or ulcerate, or 
become the seat of malignant growths. 

Acxe-keloid (see Dermatitis Papillaris Capillitii) is a 
term descriptive of acneiform lesions over the nucha and scalp, the 
symptoms including those related to changes in the hair-pouches and 
contained hairs. Acne, both of the face and back, of severe grade and 
unusual persistence, often leaves minute multiple and somewhat de- 
forming keloid growths where the sebaceous glands have been implicated 
most seriously. 

Etiology. — The origin of the disease is exceedingly obscure. Neither 
age, sex, nor previous disorder of the skin seems to have any bearing 
upon its production. It is seen in remarkably vigorous persons (more 
often in the negro race), but also in those who are weakly. The very 
young and very old are more rarely affected. 

Though not yet demonstrated, it is probable that eventually some 
varieties of keloid will be recognized as examples of cutaneous para- 
tuberculosis, the predisposition to the development of the disease in 
sites of slight traumatism being related to the toxins furnished from a 
distant focus. The race in which its lesions are most often and most 
voluminously displayed is exceedingly prone to tuberculous infection ; 
and the frequent recurrence of the disease after surgical excision and 
the peculiar lupoid aspect of certain keloid lesions are strikingly 
suggestive. 

Pathology. — According to Langerhans, Warren, Kaposi, and others, 
in all cases of keloid the papillary layer of the corium and the 
interpapillary projections of the rete downward are intact, the new 
formation being strictly limited to the middle and lower portions of the 
corium, in which there are numerous whitish, tendinous fibres of con- 
nective tissue, dispersed for the most part parallel with the surface of 
the rete. In cicatricial keloid these observers find a partial or complete 
absence of the papillae and interpapillary processes. Babes, Crocker, 
and others, on the contrary, find that the papillae and rete may be 
normal, modified, or absent in either form. Lymph-vessels with pro- 
liferated endothelium, compressed by longitudinal growth of the fibres, 



616 NEW-GROWTHS. 

pass in both vertical and horizontal planes, for the most part remaining 
patulous. There are few spindle-cells and nucleated cells. Blood- 
vessels are few in the centre of the tumor, but are numerous at the 
border and in the loose connective tissue surrounding the growth. For 
some distance beyond the tumor the adventitia of the vessel shows a 
small-cell-growth which • probably develops later into spindle-cells and 
fibres. These, with the included tissue of the corium, form the keloid. 
The sebaceous glands and coil-glands, hair-follicles, and muscles are 
pushed to one side by the new growth and often are atrophied. 

Diagnosis. — The situations of the lesions of keloid, often over the 
sternum, the infrequency of multiple tumors, its claw-like prolongations 
and yellowish-white, reddish, or grayish-white color, all point to the 
nature of the disease. 

Treatment. — The most satisfactory treatment for keloid and hyper- 
trophic scars is found in radiotherapy. Ullmann, Taylor, Pusey, 1 and 
others report instances in which a keloid or thick scar has been removed 
wholly or in part by the use of the .T-rays. In 8 cases, 1 of true 
keloid and 7 of hypertrophic scars, in which we have tried the method, 
the improvement was great in 4, good in 2, and slight in 2 cases. In 
2 instances in which the scars, due to burns from steam, were extensive 
and very disfiguring, fourteen and sixteen treatments respectively pro- 
duced a gradual disappearance during the following six months of the 
entire thickness of the growth, leaving soft, pliable scars. Removal of • 
keloid by cauterization and excision is not to be practised, as the growth 
commonly does not fail to reappear. Vidal successfully employed mul- 
tiple linear scarifications. Various stimulating applications may also be 
made with a view to promote resorption, such as the spirit of green soap, 
iodated glycerin, iodine in ointment and tincture, and mercurial, salicy- 
lated, and lead plasters. The employment of these remedies is subject to 
the danger of stimulating the growth to greater activity. Where there 
is pain anodyne unguents may be employed topically, such as freshly 
prepared belladonna plaster, or ointments of belladonna, stramonium, 
and opium. By far the most elegant of these, and the one which also 
is capable of producing an alterative effect, is the oleate of mercury and 
morphine. Laurence 2 obtained good results by scarification followed 
for several weeks by moderate pressure produced with adhesive plaster. 
Ularic and others report successful destruction of keloid with injections 
of 5 to 20 per cent, solutions of creosote in olive oil. Electrolysis has 
given good results in a few cases. Tousey, Newton, Crocker, 3 Neisser, 
and others report excellent results from injections along the growths of 
from 10 to 20 minims (0.66-1.33) of a 10 per cent, solution of thio- 
sinamin in equal parts of glycerin and water, or in alcohol. 

Internally, quinine, strychnine, arsenic, and potassium iodide have 
been exhibited with varying success. 

Prognosis. — As regards the general condition of the patient the 
prognosis is favorable. Very rarely there is spontaneous resorption of 
the nodule or tumor. Generally the latter may be expected to persist, 
after full evolution is attained, for an indefinite period of time. 

1 The Eontgen Kays in Therapeutics, p. 558. 
2 Brit. Med. Jour., 1898, ii., p. 151. 3 Diseases of the Skin, p. 942. 



PLATE XVII. 




Multiple Fibroma of the Back. 



FIBROMA. 617 

FIBROMA. 

(Lat. fibra, a fibre.) 

(Fibroma Molluscum, Molluscum Pendulum. Fr., Fibrome; 

Ger. y Fibrom.) 

Fibroma is a new-growth, single or multiple, sessile or pedunculated, 
pea-sized or of the dimensions of the largest tumors, cutaneous or sub- 
cutaneous in its connections, and constituted of connective — often com- 
mingled with other — tissue. 

Symptoms. — Fibroma is a disease characterized usually by the 
occurrence of numerous, roundish, softish, semisolid or solid growths, 
varying in size from that of a small pea to tumors of several pounds 
weight, though the neoplasm may be single. They often are called 
molluscous fibromata, as the disease was termed at one time mol- 
luscum fibrosum. When quite small they are seated within or be- 
neath the skin, where they can be distinguished as distinctly circum- 
scribed nodules, buttons, or plaques often slightly projecting. When 
more fully developed they become sessile, pedunculated, or largely 
pendulous tumors, hanging from the part to which they are attached so 
as to resemble in shape a cherry, a nipple, a pear, or a sausage. They 
are commonly covered with an integument that is natural in color 
and suppleness, though the latter may be traversed by blood-vessels ; 
sprinkled with comedones or patent orifices of sebaceous gland-ducts ; 
thinned or thickened, or in a state of ulceration ; the last named being 
usually the result of externally operating causes in tumors of large 
size. They are productive of no subjective sensation beyond the more 
or less uncomfortable tension produced by the weight of those attain- 
ing a great size. When multiple they may be seen in various degrees 
of development, covering in hundreds and even thousands the entire 
body, especially the scalp, face, trunk, genitals, and extremities. Upon 
the lids they may interfere with vision by the production of ptosis. 
To the touch they may be felt as softish, somewhat elastic, firm, or 
lobulated masses, though at times nothing but a double fold of skin 
can be perceived, or a cord-like contained body. They are often con- 
genital. When closely set together upon the skin, and of small size 
and pendulous, the features of the disease are characteristic. 

Schwimmer distinguishes between these lesions usually congenital 
(termed by him, soft fibroma), and the dense tumors of similar ana- 
tomical features (termed by him, firm, or hard, fibroma). The latter 
are circumscribed, deeply seated, very slow of development, and apt to 
induce changes in the tissue which surrounds them. They may undergo 
fatty degeneration, or ossification, or calcification. 

Departures from the type of fibroma, as described herewith, are : 
first, in the development of single lesions, the nature of which is not 
suggested by the occurrence of other similar growths in the vicinity or 
elsewhere on the body-surface ; second, in the production of poorly 
defined fibromatous infiltrations of the skin and sub-dermal structures. 
In the last case there are voluminous formations (elephant-skin, etc.), 
often composed of confluent fibromata of smaller dimensions, irregu- 



618 NEW-GROWTHS. 

larly outlined, and superficially wrinkled, mamniillated, or nodulated. 
In these instances, as a consequence of gravity, friction, skin-infection, 
or intercurrent erysipelatous and other inflammations, ulceration may 
occur and, still more rarely, gangrene. 

Pure types of fibroma are rarer than the mixed forms. Many of 
the tumors, whether single or multiple, are made up of fibrous, connec- 
tive, fatty, adenomatous, and nerve-tissue. 

The sites of election of fibromata are the anterior and posterior sur- 
faces of the trunk, the scalp, and other regions of the head, and the 
extremities, though all parts of the body may be invaded extensively, 
the palms and soles only excepted. 

Fibroma Simplex (Acrochordon, Soft Warts. Ft., Verrues 
charnues). — The first appearance of the disease sometimes may be 
recognized as a roundish spot over which the skin is uplifted. It is of a 
light-pinkish color. The tumor is soft and suggests to the touch a thin- 
ning of the derma beneath. By firm pressure over such lesions when 
they have attained about a centimetre in diameter they may be pushed 
slowly downward into the skin, and the sensation is produced to 
the touch of a foramen in the derma. Fusion between the new growth 
and the skin over it is of early occurrence. The spherical or oval form 
of the tumor depends upon the directiou of the bundles of the subcu- 
taneous tissue of the part invaded. The tumors may undergo involu- 
tion, but this result is more common when the patient is under thirty 
years of age. Dermatolysis is produced by great activity of the growth 
of one, or fusion of several, tumors, by which a flap of skin is formed. 

Some of the tumors, usually in young subjects, suggest, when handled, 
that they contain boiled vermicelli or a number of thread- worms. The 
soft and gelatinous quality of the neoplasm in earlier life is believed to 
be proportioned to the age of the subject, and a rapid development and 
succulence of structure are only conditions of imperfect evolution, and 
are not common in older patients, in whom the tumors are firmer and 
grow more slowly. 

When involution occurs after maturity of the lesions has been attained 
the softish contents of the tumors are adherent to the cutis above, and 
the cutaneous atrophy is proportioned to the rapidity of development 
of the growth and the firmness of its structure. Then ensues a 
purse-like pedunculation of the tumor, produced by encroachment 
of the skin upon its pedicle, rendering its invagination, supposably 
possible before, afterward difficult or impossible. Gradually there- 
after the neoplasm loses its skin-connection. Eventually in many cases 
only fibrous cords are left, evidently attached to the connective tissue 
beneath, the skin-color paling as the vascular tension correspondingly 
diminishes. Soon the dermal foramen closes, and the involutive process 
is at an end. Then empty and wrinkled pouches or purses of integu- 
ment are left, the further skrinkage of which produces multiple warty 
or nipple-like elevations of tissue (under the microscope recognized as 
fibrous structures with an epithelial envelope), much in color like the 
virgin nipple or the scrotum of a boy. From four months to a year 
are requisite for the mature development of the tumors, and nearly as 
long a period for the completion of the process of involution. The 



PLATE XVIII. 




Fibroma Pendulum. 



FIBROMA. 619 

dermatolytic flap is permanent. Taylor believes that there is the 
closest possible relation between fibroma and the verrucous growths 
called acrochordon and ecphyma mollusciforme. 

Dermatol ysis (Chalazodermia, Pachydermatocele, Fibroma 
Pendulum, Lax or Kelaxed Skin) is a condition which may be 
congenital, or which, as appears in what precedes, may be produced by 
fibroma and follow involution of its lesions. In other cases it is ap- 
parently spontaneous and diffuse, but then it is probably the result of 
some preceding condition that has been unnoticed. The skin of patients 
thus affected is in a condition resembling that of the young of several 
of the larger among the lower animals (pups of large hounds, etc.), where 
enormous flaps of skin may be gathered up between the fingers and 
extended a foot or more from the underlying tissue. On releasing such 
folds the skin retracts to its former position. The skin in these cases 
usually is thickened, but it may be stretched to a considerable tenuity, 
as in the case of a man lately exhibited who could cover his face 
with skin drawn up from the surface of the chest. The integument 
may be externally normal to the view or pigmented. It may be the 
seat of molluscous tumors ; and either insensitive or normally sensitive, 
or the seat of painful sensations. Usually all the functions of the 
integument are preserved. 

The anomaly is always partial and limited to either the face (the 
lids), the neck, the chest, the belly, or the genital region. The disease 
may be congenital or acquired. 

Dermatolysis, as thus recognized, is to be distinguished from the 
laxity of skin apparent in the senile condition and after distention from 
the presence of tumors, pregnancy, etc. Usually, however, in the last- 
named group of cases it is the subcutaneous tissues which are relaxed 
rather than to any unusual extent the skin itself (e. g., the mammary 
glands of women of advanced years, and the abdominal muscles after 
distention of the belly). 

Etiology. — Fibroma is peculiar to neither sex ; and, though observed 
in adults, commonly is developed first in childhood, often in infancy, 
and may be congenital. It cannot be claimed as peculiar to any race, 
though in America negroes probably have furnished the largest field for 
its observation. Hebra called attention to the low standard of physical 
and mental development of the subjects of the disease seen by him, a 
fact well illustrated in a case recently presented, the patient being an 
exceedingly myopic, poorly nourished white male dwarf, whose body 
literally was covered with fibromata from the scalp to the feet. In 
view of this well-established clinical fact, the hereditability of the 
disease, which is rendered probable by recorded observations, seems 
capable of explanation. It has been noted in three successive genera- 
tions and in seven children in one family. The cause of the disease is 
unknown. It is without question related to a vice of local develop- 
ment under the influence of a constitutional predisposition. 

Pathology. — Simple, soft fibroma of the skin is seen under the 
microscope to be a variety of myxo-fibroma and originates in gelatinous 
connective-tissue elements, which undergo metamorphosis into bundles 



620 NEW-GROWTHS. 

of fibres, the tumors always exhibiting more of the formed fibrous tissue 
in the outer, and the formative or protoplasmic material in the central 
parts of the mass. In young tumors the fibres are delicate and form a 
loose network containing many spindle-shaped cells. As the growth 
becomes older and harder the fibres become coarser and more closely 
united, forming compact fibrous tissue in which there are very few 
cells. The vascular supply of fibromata is usually slight. The fibrous 
bundles pass downward and unite with those of the derma or sub- 
cutaneous tissue, forming thus a firm attachment for the pedicle of all 
pedunculated tumors. There is some question as to whether these 
growths originate in the deep interspaces of the corium or in the con- 
nective tissue about the hair-follicles or fat-globules. 

A very large number of fibromata are of the so-called "mixed" 
variety. Some spring from the nerve-sheaths, and actually contain 
nerve-filaments (neuro-fibroma) ; others from muscular, vascular, and 
glandular tissues, the compound tumor receiving in this way a part of 
its constituent elements; often warty growths form with participation 
of epithelium in the connective tissue, constituting thus an epithelioma 
(so-called "papilloma"). The large pendulous tumors of nsevus lipom- 
atodes may be examples of mixed fibromata, the surface of which is 
composed of pigmented and hairy skin. 

Diagnosis. — The tumors of molluscum fibrosum are to be distin- 
guished clinically from multiple cutaneous sarcomata by the violaceous 
or reddish color of the latter, the absence of pedunculation, the greater 
tendency to ulceration, and their evidently malignant character. From 
tubercles of lepra they are differentiated by the entire absence of con- 
stitutional impairment and their general development in far greater 
multiplicity. The tumors of molluscum epitheliale differ in their con- 
tents, their superficial location, and in the frequent presence of the 
dark punctum at their summits. 

Neuroma is usually painful ; lipoma less frequently multiple and 
pedunculated, and more suggestive, when handled, of a " pillowy " 
sensation to the touch. Warty growths are readily distinguished by 
their verrucous summits ; and the gummata of syphilis, by the con- 
comitant or prior symptoms of the existence of lues. 

Treatment. — The treatment of large single fibromata is surgical, 
involving the employment of knife, ligature, ecraseur, or galvano- or 
thermo-cauterization. Multiple lesions are often so numerous as to 
forbid such interference. When there is a distinct vice of development 
or inherited tendency to the disease little can be accomplished in the 
way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their evo- 
lution is completed. Marasmus, tuberculosis, and a fatal result may 
occur. One or several of the tumors may become sources of danger 
from the occurrence in them of an active inflammation with resulting 
degeneration and septicemic consequences. The disease, however, does 
not in many cases shorten life. In general the prognosis of multiple 
fibromata may be regarded as unfavorable. 



NEUROMA. 



621 



NEUROMA. 1 

(Gr. vevpov, nerve.) 

(Tumor of the Nerves. Fr., Nevrome ; Ger., Neurom.) 

Neuroma is a new-growth consisting of one or several tubercles 
developed in the skin and composed of elastic, fibrous, and connective 
tissue with fibres of nerves. 

Symptoms. — But few cases of this rare disease are recorded. The 
description appended is a summary of the symptoms detailed in the 
reports of Duhring, 2 of Rump, 3 and of Kosinski. 4 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks numerous dis- 
seminated and defined, pinhead- to hazel-nut-sized, spherical or oval 
nodules or tubercles. They were either painful, or painless at the out- 
set and painful later. In Rump's case, which was a sample of the 
false neuroma of Virchow (fibroid tumor of the nerve), there was no 
pain throughout the course of the disease. 




^¥ 



Neuroma of the skin: external appearance. (Duhring.) 

The nodules were not arranged along the tracts of nerves ; were 
immovable, dense, and elastic ; were fixed in the corium and extended 

1 For a review of the subject, with full bibliographv, see Krzvsztalowicz, Monatshefte, 
1903, xxxvi., p. 421. 

2 " Case of Painful Neuroma of the Skin," Amer. Jour. Med. Sci., 1873, lxvi., p. 
413 ; also supplement to the same, with cuts, Ibid., 1881, Ixxxii., p. 435. 

3 Arch. f. path. Anat. u. Phys., 1880, lxxx., p. 177. 
* Centralbl. f. Chir., 1874. 



622 



NEW-GROWTHS. 



below it. They were purplish or pinkish in color; and the skin 
between them was unaltered, or like that enveloping the lesions, dry, 
uneven, and desquamative. The tubercles were both tender and pain- 
ful, the pain being excruciating, paroxysmal, usually lasting in Dull- 
ing' s patient for an hour, and radiating. It was aggravated by tem- 
perature-changes, mental emotion, and movement. 

Histologically these tumors are composed of a mixture of fine con- 
nective tissue with medullated and non-medullated nerve-fibres ; and 
should properly be called neuro-fibromata. Sections of the growth in 
Duhring's case showed anatomically a connective-tissue stroma, inter- 
woven with fibres for the most part lying parallel with one another, 
each fibre composed of a finely granular central substance surrounded 
by a sheath containing numerous, elongated, oval, somewhat granular 
nuclei. There were also yellow elastic tissue, blood-vessels with thick- 
ened and nucleated walls, and about the latter lymphoid, cell-like 
bodies. There was entire absence of unstriated muscular and fibrillar 

Fig. 69. 




Microscopic structure of neuroma. (Duhring.) 



connective tissue. The specimen represented the true amyelinic neuro- 
mata of Virchow. In Kosinski's case non-medullated nerve-fibres and 
connective tissue were also discovered. In both cases exsection of a 
portion of nerve (brachial plexus, of the one ; and small sciatic, of the 
other) was followed by considerable diminution of pain and almost 
entire disappearance of the growths. In Rump's case, which, as stated 
above, represented the fibromated and so-called fibro-nucleated tumors 



PLATE XIX. 

Fig. 1. 




Fig. 2. 

Fig. 1. Xanthoma of the Hands, Elbows and Knees. 
Fig. 2. Xanthoma Tuberosum of Penis and Scrotum. 



XANTHOMA. 623 

of Virchow, the nodules were strung upon the same nerve, " like beads 
upon a rosary/' and were similarly displayed upon its branches. 
Spinal, cerebral, and sympathetic fibres were all involved. 

Duhring, in commenting upon these rare cases, calls attention to the 
distinction between purely cutaneous lesions and the generally solitary, 
movable, and " painful subcutaneous tubercle." 

Knauss 1 reports a case in a girl of eleven years. There were over 
sixty tumors varying in size from a cherry to a hen's egg. They were 
situated beneath the skin, were firm and elastic, and never painful. 
Histological examination showed them to be composed of medullated 
and non-medullated nerve-fibres, and numerous ganglionic nerve-cells. 

XANTHOMA. 

(Gr. ijavdog, yellow.) 

(Xanthelasma, Vitiligoidea. Fr. y Plaques jaunatres des 

Paupieres.) 

This affection was described by Payer 2 under the title Plaques 
jaunatres des Paupieres; by Addison and Gull (1851) as Yitiligoidea ; 
by Erasmus Wilson as Xanthelasma; and by W. F. Smith (1869) as 
Xanthoma, the name now generally accepted by writers. 

Xanthoma is a single or multiple new-growth involving the corium, 
and occurring as yellowish, well-defined, round or oval nodules, plaques, 
lines, or ribands ; or as diffuse infiltrations of the skin, composed of 
fibrous and fatty tissue. 

Symptoms. — Two forms of the disease are recognized : Xanthoma 
planum and Xanthoma multiplex. 

Xanthoma Planum. — The flat or plane forms of the disease appear 
as pinhead- to finger-nail-sized plaques, streaks, or bands, either quite flat 
or with slightly elevated borders, and covered with an apparently normal 
integument. In color, which may be rendered more distinct by 
stretching the skin, they vary from light- or chrome-yellow to a 
" coffee-and-milk " shade ; and in shape they may be punctiform, 
spherical, oval, elongated, or of irregular outline. They are distinctly 
circumscribed, and when gathered between the thumb and finger are 
soft and smooth, and do not produce a sensation of the presence of a 
foreign material. The plaques, examined closely, are seen to be made 
up of an aggregation of millet-seed-sized, yellowish nodules, each pro- 
vided commonly with a somewhat reddish central point. The plaques 
are most often seen upon the eyelids (Xanthoma Palpebrarum), near 
the inner canthus, the upper more often than the lower (though all 
four lids often are involved), where the xanthoma plaques may be dis- 
posed symmetrically about the two orbits, first appearing on one side ; 
but they may invade also the periorbicular region, as also, rarely, the 
cheeks, the nose, the ears, and the nucha. They are rarely productive 
of subjective sensation, being occasionally the seat of slight pruritus. 
They develop very slowly, and after attaining an average size rarely 
increase or diminish. This is the commoner form of the disease. 

1 Virchow's Archiv, 1898, cliii., p. 29. 

2 Traite prat, des Maladies de la Peau, Paris, 1836. 



624 NEW-GROWTHS. 

Xanthoma Multiplex 1 (Xanthoma Papulatum, Tubercu- 
latum, Tuberosum) is the form in which the lesions, usually first 
manifested in the sites of election and in their simplest development, 
proceed to a gradual invasion of the trunk and extremities. The 
regions of greatest pressure, outside of the lids and cheeks, are sites 
of preference, as, for example, over the elbows, knees, palms, and 
buttocks, but the ears, neck, and upper chest may be involved. Occa- 
sionally the mucous surfaces of the mouth, of the respiratory, and of the 
gastro-intestinal tracts are involved, as also the surfaces of the peri- 
toneum, endocardium, and larger arteries. The genital region, palate, 
oesophagus, spleen, trachea, and cornea may be seats of the disease. 
Papular and tubercular lesions may coexist with the plane lesions 
described above, and scarcely differ from the latter save in a greater 
development. The lesions are whitish or yellowish papules, plaques, 
and tubercles, circumscribed in contour, millet-seed- to nut-sized, at 
times much larger, covered with an unaltered epidermis, and deter- 
minable by palpation as having greater consistence than the flat macules. 
They are seen less frequently upon the lids, but occur upon the scalp, 
cheeks, palmar and plantar surfaces, the genital region, and about the 
joints of the digits. 

In rare cases the tubercles may coalesce to form sessile or pedun- 
culated, nut- to hen's-egg-sized tumors which are firmer as a rule than 
the smaller lesions (Cary 2 and Chambard 3 ). 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply imbedded in the corium, 
elevated to the extent of one-fourth of an inch above the general level 
of the integument, and irregularly furrowed or lobulated superficially. 

Other cases display unusual features of this disease. In one there 
are flattened ribbons, exhibiting xanthomatous changes in both palms, 
stretching at right-angles to the long axis of the hand ; in a second 
and somewhat rare form of the disease isolated xanthomatous papules 
are attached somewhat regularly to the edges of the lids of both eyes, 
the upper and lower equally, while large pinhead-sized and equally 
isolated yellowish masses are visible below the orbits on each cheek. 

In certain cases the disease is accompanied by a generalized colora- 
tion of the skin in a yellowish shade, which has been variously inter- 
preted as a xanthomatous dyschromia and as a true icterus. The 
former is the more probable explanation of the fact, as in such cases 
the urine and viscera have been found normal. A woman presenting 
one of the extreme phases of this icteroid xanthomatous condition of 
the skin was shown at the International Congress of Dermatology in 
London in 1896. 

Korach 4 has described the case of a woman twenty-five years old, 
suffering from chronic icterus produced by closure of the ductus 

1 For bibliography, see Eichter, Monatshefte, 1903, xxxvi., pp. 57 and 126 ; and 
Leven, Archiv, 1903, lxvi., p. 61. 

2 Annales, 1880, s. 2, i., p. 75. 

3 Arch, de Phvs. norm, et path., 1879, s. 2, vi., p. 330. 

4 Deutsch. med. Wchnschrft, 1881. 



PLATE XX. 










Xanthoma Tuberosum of Hands. 




■V 






V 



? 'j 



*'**** 







X 
X 

h 





XANTHOMA. 625 

choledoclius. Beside the typical patches of xanthoma on the lids, 
the skin-surface was generally and similarly affected. Thus the 
extensor faces of the extremities, the palms of the hands, nates, and 
other parts were extensively covered with sago-grain- to pepper-corn- 
sized papules and tubercles of xanthoma, both flat and elevated. 

Occasionally the tubercles exhibit a fine vascularization ; and when 
there is a coincident jaundice the skin between isolated lesions is also 
tinted with the color of the xanthoma nodules. The jaundice, so- 
called, is rather common in the multiplex forms ; and even when not 
readily recognized the skin, at first sight of normal tint, is seen to be 
somewhat deeply colored in a shade of reddish yellow. As a rule, 
there are scarcely distinguishable subjective sensations, patients com- 
monly applying for relief of the resulting facial disfigurement. Occa- 
sionally burning and pricking, and rarely even painful sensations are 
produced. 

The course of most cases is toward a maximum of development, 
after which the process ceases. In a few instances, usually not palpe- 
bral, complete involution has occurred spontaneously. The variations 
noted in the color of the plane and elevated forms of xanthoma are 
from a light-yellow to a deep-brownish and even blackish hue. Cases 
occurring in children and infants seem to exhibit nearly the same 
features as those seen in adults. 

Xanthoma Solitarium. — In rare instances a single lesion of 
xanthoma may be recognized over the body-surface (eyelids, chest, 
thigh, leg). In these cases the lesion usually attains the size of a large 
coin and is well elevated and defined, involving the entire thickness of 
the skin. 

Xanthoma Elasticum (Pseudo-xanthoma Elasticum) has 
been recognized by Balzer, 1 Besnier, 2 Doyen, and Bodin. 3 In this 
condition large coils of elastic tissue surrounded the follicles, the fibres 
being swollen and degenerated. The lesions were pin-head- to pea- 
sized, papular, yellowish patches occurring over the flexor folds, about 
the umbilicus, the clavicles, and the extremities, the eyelids being un- 
affected. No xanthoma- nor fat-cells were recognized. 

Etiology. — The causes ,of the disease are obscure. In a few cases 
the lesions are observed first in early childhood, though they are 
encountered chiefly in middle and later life after the fortieth year. 
Women are affected rather more often than men. 

The belief is growing that xanthoma is due to embryonic and local 
causes. Many instances are on record in which several members of a 
family were affected. Torok and T. C. Fox have each reported families 
in which members of three generations presented the disease. The 
mother of the patient exhibiting multiple lesions upon the elbows and 
knees, whose case was selected for illustration of these pages, presented 
plane lesions of xanthoma near the inner canthi of the eyes. The 
studies of Torok 4 in this direction are instructive. The association of 

1 Arch, de Phys., 1884, ser. 3, p. 65. 

2 Trans, of Kaposi, vol. ii., p. 336 

3 Annates, 1906, i., p. 1073. 

4 Ibid., 1893, s. 3, iv., pp. 1109 and 1261. 

40 



626 NEW-GROWTHS. 

xanthoma with disease of the liver, rheumatism, gout, ovarian disease, 
migraine, syphilis, carcinoma, hydatids, and other disorders cannot be 
denied for certain cases, but in the majority no such association can be 
recognized. Multiple plane lesions of the lid in a middle-aged woman 
have succeeded a dermatitis of that region, induced by accidental con- 
tact with a corrosive solution of mercury. 

Pathology. — The anatomy of xanthoma has been investigated spe- 
cially by Chambard, Balzer, Touton, 1 Torok, and others. The process 
is a connective-tissue new-growth, containing cells infiltrated with fat- 
granules. Aside from the new-formed connective tissue and endothelial 
cells there are seen between the interlacing fibres the characteristic 
" xanthoma-bodies." These are cells varying greatly in size, having a 
distinct membrane, granular or fibrillated protoplasm, and large round 
or oval vesicular nuclei, which vary in number from one to a dozen 
or more. 

These " xanthoma-cells " are grouped especially about and along the 
vessels, and form globular masses in the deeper parts of the corium, 
though they may extend almost to the rete. They are more or less 
infiltrated with fat-granules, and correspond closely in structure to the 
developing fat-cells of normal connective tissue, but, as Torok has 
shown, they never go on to the formation of a fully developed cell 
containing one large drop of fat, and Unna finds they do not respond 
to staining and other tests as do the fat-containing cells found in other 
tissues. There is seen also in the growth a transitional series of 
bodies between the connective- tissue corpuscles and the characteristic 
" xanthoma-cells." 

The epidermis is usually unchanged, though it, together with the 
papillary layer, may be slightly thinned, and there is frequently a 
deposit of a yellowish-brown pigment in the deeper layers of the rete. 
The growth is almost wholly confined to the deeper parts of the corium, 
though occasionally portions extend to the subcutaneous tissue and may 
surround the coil-glands and hair-follicles. The sebaceous glands may 
be few, but are unchanged and are not, as was formerly supposed, con- 
cerned in the process. There is often a deposit of pigment in the corium, 
both free and in the cells, but the characteristic color of xanthoma is 
undoubtedly due to the fat-granules. 

The icterus and hypertrophy of the liver which sometimes complicate 
xanthoma are probably secondary and caused by the presence of the 
growth in the liver or in the biliary passages. 

Pollitzer 2 states that eyelid xanthoma is due to a slow fatty degenera- 
tion of the fibres of the orbicularis muscle analogous to the more rapid 
degeneration of muscles which sometimes follows acute infectious dis- 
eases. He finds the xanthoma-bodies to be fragments of degenerated 
muscle-fibres, and believes that this form of the disease has no connection 
whatever with the generalized forms. 

Chambard, Morris, Crocker, and a few others believe the primary 
process is an inflammation which is followed by a fatty degeneration of 

1 "Vierteljahr., 1885, xii., p. 3, with reference to previous reports. 

2 Jour. Cutan. Dis., 1897, xv., p. 367. 



XANTHOMA. 627 

the cells. 1 Balzer's conclusions as to the parasitic nature of the disease 
have not been verified by more recent investigators. 

Xanthoma does not develop exclusively in the skin. Lesions have 
been recognized in the heart and large vessels, liver, spleen, oesophagus, 
and trachea. Lieberthal exhibited a young patient before the Chicago 
Dermatological Society with multiple lesions of xanthoma where the 
sheath of the tendo Achillis was involved. 

Diagnosis. — Milia occasionally occur in groups in the form of oval 
plaques upon the lids, but are distinguishable from xanthoma by the 
possibility of expressing their contents. 

The diagnosis from all other lesions is readily made when consider- 
ation is had of the peculiar yellowish or saffron-like hue of xanthoma, 
and the common situation, form, and general characteristics of its plane 
or nodular lesions. 

Pollitzer has reported a case of multiple dermoid cysts in which were 
present the clinical appearances of xanthoma. A similar case has been 
under our observation. Another is reported by Pringle. 2 

When xanthoma is represented by a single lesion upon the skin, the 
diagnosis may be attended with some difficulty. The distinctive differ- 
ences between xanthoma and xanthoma diabeticorum are detailed in 
connection with the description of the disease last named. 

Treatment. — Erasion and excision are the usual methods of re- 
moving xanthoma. Care should be taken in such operations to avoid 
a consequent ectropion when the operation is performed upon the skin 
of the eyelids. The Paquelin knife is objectionable on account of the 
radiation of heat to the globe of the eye. With the tumor slipped 
through an aperture in a thin sheet of asbestos paper, such as now is 
found in the market, this danger may be obviated. Morrow employs 
25 per cent, salicylic acid plaster. Roberts makes a salicylated collodion 
paint — 2 parts of salicylic acid, 1 each of chrysarobin and castor-oil, 
and 4 of flexile collodion. 

The modern method, however, of treatment by electrolysis is prefer- 
able to others. The technique is the same as that employed for hyper- 
trichosis and for the removal of soft moles. Caustics also have been 
employed successfully. Besnier employs phosphorus internally, fol- 
lowed by turpentine, by which the course of the disease is said to have 
been relieved. Wilson, with the same end in view, employed nitro- 
muriatic acid, bitters, and blue pill. McGuire reports the removal of 
xanthoma by applications of monochloracetic acid. 

Prognosis. — The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
Some cases of xanthoma tuberosum, with xanthochromia and involve- 
ment of the inner coats of the larger vessels, prove serious. 

1 A discussion of this question and a resume of literature are found in Brit. Jour. 
Derm., 1892, iv., p. 237 et seq. 

2 Brit. Jour. Derm., 1903, xv., p. 292. 



628 NEW-GROWTHS. 

XANTHOMA DIABETICORUM. 1 

(Glycosuric Xanthoma.) 

Xanthoma diabeticorum is a rare eruptive disease, occurring in the 
subjects of glycosuria, characterized by the development on the skin 
of multiple non-inflammatory, whitish globoid papules, with a reddish 
base, resembling pustules and productive of mild, subjective sensations. 

This disorder has been well illustrated by three excellent por- 
traits showing the features of the malady in a case reported by Kobin- 
son. 2 Instances of the disease have been recorded also since the cases 
of Addison and Gull (1851) by Hillairet, Morris (who was the first to 
claim for it an independent position in the list of cutaneous affections), 
ourselves, 3 and many others. It is a disorder affecting more often 
glycosuric than diabetic patients, and as it is not demonstrably a 
xanthomatous affection the name by which it is recognized most com- 
monly is doubly unfortunate. 

Symptoms. — The lesions are usually multiple and exceedingly 
numerous, discrete, or confluent, and not rarely grouped, pinhead- to 
pea-sized, firm, well-defined, conical, or acuminate papules. At the 
apex may be recognized a yellowish centre with reddish areola, which 
may be made to disappear temporarily under pressure. The appear- 
ance when viewed at some distance is suggestive of a pustule. Sub- 
jective sensations of itching, pricking, etc., may be produced. The 
lesions are visible over the buttocks, loins, elbows, knees, and extensor 
faces of the limbs in general — the scalp, face (brows, lips, nose), about 
the angles and over the mucous surface of the mouth, and the palms 
and soles. But one case has been reported as occurring on the eyelids. 
The eruptive lesions are likely to be of sudden occurrence and abun- 
dant at the outset. They are occasionally firm and generally soft and 
compressible to the touch. Occasionally they occur as punctate 
linear, riband-shaped, or flattened lesions. In a large number of 
patients with trunk-lesions the abdomen is fat-distended. After 
remaining upon the surface for a few months or years they may 
wholly disappear without leaving a trace of their existence, or the 
eruptive elements may in part only disappear. Under appropriate 
treatment they may disappear with surprising rapidity. 

Etiology. — In seventeen of twenty-one cases reported, glycosuria 
has been recognized, and Johnston calls attention to the fact that in 
nearly every case the patient has been described as stout, florid, or 
obese. The majority of the patients have been male subjects and 
usually in a condition of fair nutrition ; often they have been con- 
sumers of beer in large quantities. In yet other cases, especially in 
young subjects, there is malnutrition, and even cachexia. The patient 
under our observation, whose genitalia are represented in the accom- 
panying plate, suffered from diabetes insipidus, passing over a gallon of 
water daily without a trace of sugar. He suffered from chills and was 

1 For bibliography, see Leven, Archiv, 1903, lxvi., p. 61. 

2 Internat. Atlas, 1890, iv. 

3 Paintings in oil showing the lesions in two patients were exhibited to the Amer. 
Derm. Assoc, in New York, 1898. 



PLATE XXII. 




Xanthoma Diabeticorum. 



XANTHOMA. 629 

undersized. In yet other cases albuminuria, nephritis, and jaundice 
have been present. 

Pathology. — Histologically the disease does not differ essentially 
from the ordinary form of xanthoma, except that inflammatory changes 
are more marked, there is less connective-tissue formation, and there 
are fewer of the xanthoma-cells than in the common variety. The 
lesions, moreover, are found usually near the coil-glands and follicles. 
Torok, Johnston, and others believe the disease to be an exudative der- 
matitis, terminating in a granulo-fatty degeneration which is quite dis- 
tinct from the heterotopic, arrested development of fat seen in ordinary 
xanthoma. 

Diagnosis. — The difference between xanthoma and xanthoma dia- 
beticorum is based upon the following points : In xanthoma of glyco- 
suria the sudden evolution and involution of the cutaneous lesions, the 
occasional firmness and solidity of the latter as distinguished from the 
softness of the ordinary forms, and the appearance of inflammation in 
the glycosuric as distinguished from the hypertrophic changes in the 
other variety. In xanthoma diabeticorum the yellowish apex is not at 
first apparent (though it may be wholly wanting), nor in all the lesions, 
and when it exists is due to epidermal changes, and not to those occur- 
ring in the corium, as in xanthoma. Other characteristic features of 
the xanthoma of diabetic subjects are the frequent absence of striae and 
patches, of jaundice, and of eyelid-lesions, the presence of mild sub- 
jective sensations, the grouping of the lesions about the hair-follicles 
(well marked in Robinson's case), and the absence of diabetes mellitus 
in most of the palpebral cases on record. This side of the question is 
presented by Johnston in reporting a case and in giving a summary of 
the twenty cases so far recorded. 1 

On the other hand, it is urged by Besnier and Doyon that the gly- 
cosuria is simply an irritating cause which explains the differing symp- 
toms of xanthoma in the two classes of patients. Surveying the litera- 
ture of xanthoma, they find patients without diabetic symptoms suffering 
from atrocious pruritus and most of the special features claimed as 
peculiar to diabetic xanthoma of glycosuria. A woman, however, in 
middle life, recognized as the subject of diabetes mellitus (not insipidus), 
examined with special care, exhibited merely the common form of sym- 
metrical and plane eyelid-lesions. It is difficult to determine what are 
the relations, if any, between these two forms of xanthoma. 

The Treatment of the disease, medicinal and dietetic, is largely that 
of glycosuria. Robinson's patient recovered after the use of small 
doses of Fowler's solution. Local treatment may be employed as in- 
dicated in any case. 

The Prognosis is favorable, the majority of the patients eventually 
recovering. 

1 Jour. Cutan. Dis., 1895, xiii., p. 401 ; and Ibid., 1900, xviii., p. 387. 



630 NEW-GROWTHS. 



COLLOID METAMORPHOSIS OF THE SKIN. 1 

(Colloid Milium [Wagner], Hyaloma. Fr., Colloidome 
miliaire [Besnier]; Ger., Hyalom der Haut.) 

Relatively few cases of this rare disorder have been reported. The 
lesions occur chiefly on the upper two-thirds of the face, especially on 
the forehead and about the orbits. In C. J. White's case 2 the backs of 
the hands also were involved. They consist of pinhead- to millet-seed- 
or even split-pea-sized, sharply circumscribed, irregularly rounded, 
flat papules, lemon-yellow in color, having a peculiar glistening, trans- 
lucent appearance suggestive of vesicles. They project but slightly 
from the skin, and, on puncture, give exit to a soft, gelatinous mass, 
at times accompanied by a droplet of blood. Some of them may be 
surrounded by very slight telangiectases. They develop slowly, often 
in groups, the individual papules remaining distinct even when two 
or more unite. Frequently a papule becomes depressed in the centre ; 
or becomes inflamed and covered with a crust which falls and leaves a 
shallow depression but not a true scar. 

Etiology. — The cause of the disease is not known ; it occurs alike 
in men and women, usually after the forty-fifth year of age. A male 
patient presented at our clinic was twenty-five years of age only. In 
most of the cases reported the individuals lived an outdoor life and 
were much exposed to the elements. 

Pathology. — This has been studied by Balzar, Besnier, Reboul, and 
others. Wagner's belief that the process begins in the sebaceous 
glands is now practically discarded. Colloid degeneration is found to 
affect the connective-tissue and elastic fibres of the derma, which may 
become involved over considerable areas. The changes are especially 
noticeable about the vessels and nerves and about the sebaceous and 
coil-glands. The glands themselves, and all the epithelial structures, 
except the endothelia of the vessels, usually escape. In sections exam- 
ined by us removed from a clinical patient a few rete-cells and a few 
cells of the coil-gland ducts were transformed into or infiltrated with 
colloid substance. This disease is not identical with multiple benign 
cystic epithelioma (hidradenoma), in which the epithelial cells play an 
important part. 

Diagnosis. — The disease is apt to be confounded with xanthoma, 
hydrocy stoma, adenoma sabaceum, and multiple benign cystic epithe- 
lioma (hidradenoma). From the last-named disease the diagnosis is 
often very difficult or even impossible without the aid of histological 
examination. 

Treatment. — The nodules may be removed with a sharp curette or 
by electrolysis. 

1 For full bibliography, see Jnliusberg, Archiv, 1902, lxi., p. 175. 

2 Jour. Cutan. Dis., 1902, xx., p. 49 (with review of literature). 



ADENOMA OF THE SEBACEOUS GLANDS. 631 



ADENOMA OF THE SEBACEOUS GLANDS. 1 

(Adenoma Sebaceum. Fr., Adenomes sebaces [Balzer and 
Menetrier], Adenomes sebaces cancroid aux, Acne Cancroi- 

DALE.) 

The several forms of adenoma of the sebaceous glands may be 
assigned to two categories, the benign and the malignant. 

Acquired Benign Growths are pinhead- to pea-sized, sessile, 
spheroidal, oval or acuminate bodies, occasionally presenting points of 
whitish appearance suggestive of milium. They are situated chiefly 
over the face (forehead, furrows beside the nose). They are always 
covered with an unchanged epithelium and in color present the hue of 
the normal skin. 

Congenital Benign Growths are represented by the verrucous 
and vascular nsevi of Pringle and Darier. They increase slowly after 
birth and attain a notable development at about the period of puberty. 
They also are found about the regions of the face named above, includ- 
ing the chin and the mouth. The lesions are pinhead- to bean-sized, 
and differ from those above described chiefly in the color they present, 
which varies from a yellowish white to a deep brownish red ; often 
the surface is vascularized by the presence of minute capillaries. 
They are sometimes discrete, often confluent, and may be commingled 
with comedones, acne-pustules, pigmented patches, and the lesions of 
facial seborrhoea. In the majority of cases other defects of the skin, 
such as warts, nsevi, small papillomata, and pigment-spots, are present, 
while many of the patients reported have been mentally deficient or 
epileptic. 

The two forms named above are benign lobulated tumors of the 
type of sebaceous adenoma ; the last-named group being distinguished 
by delicate telangiectases over the surface and a verrucous structure. 

Malignant forms of Sebaceous Adenoma occur when the skin 
is in the senile state. They begin with the symptoms of an irritable 
acne or seborrhoea, greasy crusts being displayed here and there, par- 
ticularly over the surface of the face ; or comedones of unusual 
type ; or papulo-pustules that do not pursue the course of those seen 
in earlier years. Ulceration attacks the lesion which at first seemed 
benign, and the issue is , the development of an epithelioma. Pick 2 
reports a case in which small epitheliomatous tumors formed similar to 
those seen in multiple benign cystic epithelioma (q. v). 



Etiology. — The cause of these growths is not known. The majority 
of them are congenital, and those also which develop later in life may 
be congenital in origin. Most of the cases reported have been in the 
poor and in those of defective mental development, but cases are seen 
also in the well-to-do and intelligent. 

1 For bibliography, see Darier, La Pratique Derma tologique, vol. i., p. 284; Pezzoli, 
Archiv, 1900, li'v., p.* 192; Pick, Ibid., 1901, lviii., p. 201; and Marnllo, Zeitschrift, 
1902, ix., p. 166. 

2 Loc. cit. 



632 NEW-GROWTHS. 

Pathology. — The histology of these bodies has been studied by 
Pringle, Darier, Balzer, Crocker, Pollitzer, and others. There is 
hyperplasia of the sebaceous glands, which are numerous and large. 
Beyond this observers do not agree, and further study of the subject 
is necessary. Pringle described an interpapillary hypertrophy ; Balzer 
found small cysts in both sebaceous and sweat-glands ; Crocker reported 
an increased development of the coil-glands and hair-follicles, in addition 
to hyperplasia of the sebaceous glands. 

Diagnosis. — The history of the disease, which begins in early life 
and develops gradually ; the persistency and permanency of the indi- 
vidual lesions situated chiefly on the middle of the face and specially 
in the naso-labial folds ; the frequent occurrence of telangiectases with 
the papules above described ; and the absence of suppuration or ulcer- 
ation will usually suffice for a diagnosis. In colloid milium the lesions 
are usually few in number, are situated chiefly on the frontal and 
orbital regions, have a peculiar yellowish, translucent appearance, and 
are not so much modified by telangiectases. In multiple benign cystic 
epithelioma the lesions occur on the forehead and also on the trunk. 
Both of the two last-named diseases, however, may so closely resemble 
adenoma sebaceum as to render the differential diagnosis impossible 
without the aid of histological examination. 

Treatment. — Neither internal remedies nor external applications 
have any influence upon the lesions. The treatment is, therefore, 
surgical and calls for the employment of the knife, the curette, or scar- 
ification, depending upon the size, number, and location of the lesions. 
In several cases the latter have been removed successfully by means 
of electrolysis. 

ADENOMA OF THE COIL-GLANDS. 

Although the majority of cases formerly described as adenoma of 
the coil-glands are now classed with multiple benign cystic epithelioma, 
a few well-authenticated examples of the disorder are reported. 1 
Perry 2 describes a case, illustrated by a chromo-lithograph, of a 
woman upon whose face and trunk millet-seed- to small pea-sized 
nodules were visible, lasting for nearly twenty years. Upon puncture 
a clear fluid could be expressed from each. On section the coils of 
the sweat-glands were found enormously increased in size, and there 
was pigmentation of the gland-cells. Braiins 3 reports a case of widely 
distributed sweat-gland adenoma with cystic formations. 

The Diagnosis of this rare disorder can be made only with the aid 
of the microscope. 

The Treatment is surgical, by means of the knife, curette, cautery, 
or electrolysis. 

1 Fordyce gives a summary of the subject in Morrow's System, vol. iii., p. 618. 

2 Internat. Atlas, 1890-91. 

3 Archiv, 1903, liv. ? p. 347 (with bibliography). 



MULTIPLE BENIGN CYSTIC EPITHELIOMA. 633 



MULTIPLE BENIGN CYSTIC EPITHELIOMA. 1 

(Adenoma of the Sweat-glands [Perry], Epithelioma Ade- 
noides Cysticum [Brooke]. Fr., Cellulome Epitheliale 
Eruptif Kystique [Quinquaud], Cystadenomes Epithe- 
lieux Benins [Besnier], Hydradenomes Eruptifs [Jacquet 
and Darier], Syringo-cystadenome [ToroK] ; Ger. y Gutar- 
tiges Epithelioma, Verbunden mit Kolloider Degen- 
eration [Phillipson].) 

The name selected as the title of this chapter is that given to the 
disease by Fordyce, whose presentation of the subject forms 2 the basis 
of the following description. 

The disease is most common on the face, neck, and upper extremi- 
ties, but may develop on any part of the body. It is characterized by 
the appearance of small, pearly, pale, yellow or pinkish-colored tumors 
varying in size from a small pin's head to that of a pea. Larger 
lesions are exceptional. The tumors are firmly imbedded in the skin 
and also project above the surface ; they are round or oval, solid and 
painless to the touch, the larger ones being tense, lucent, and freely 
movable. Some of the tumors are translucent, suggesting vesicles ; 
others resemble milia and may be the seat of fine telangiectases ; in 
others there may be a central depression which in some of the larger 
lesions of White's case produced an appearance closely resembling 
Hutchinson's crateriform epitheliomata. The lesions are discrete, and 
are not grouped or arranged in any characteristic manner. 

In most cases the tumors are first noted at or before the age of 
puberty ; they enlarge slowly, rarely exceeding the size of a pea, and 
do not ulcerate or undergo spontaneous involution. White, 3 however, 
reports a case in a woman of forty-five on whose face were small typ- 
ical lesions of this disease, and also others in varying stages of devel- 
opment up to true epithelioma of rodent ulcer type. The diagnosis 
was confirmed by the histological examination of a number of the 
tumors of varying sizes. 

The cause of the disease is not known. In Brooke's and White's 
cases a distinctly hereditary history was obtained. 

Pathology. — The views of different observers regarding the path- 
ology of this disease are largely indicated in the names given to it by 
each. Fordyce reports that microscopical examination shows the 
tumors to be " made up of irregularly rounded, oval, and elongated 
masses and tracts of epithelial cells corresponding to those in the lower- 
most layer of the epidermis and the external root-sheath of the hair- 
follicle. The epithelial masses may be distinct, or made up of inter- 
communicating bands and tracts, in some places resembling coil-ducts. 
Cell-' nests ' are met with as in malignant epithelioma, enclosing horny, 
granular, and colloid tissue. Colloid degeneration of individual cells is 

1 For bibliography, see Darier, La Pratique Dermatologique, vol. i., p. 288 ; and 
Gassmann, Archiv, 1901, lviii., p. 177. 

2 Morrow's System, vol. iii., p. 620. 

3 Jour. Cutan. Dis., 1894, xii., p. 477. 



634 NEW-GROWTHS. 

also encountered in the cell-masses. The connective tissue about the 
cell-collections is somewhat condensed, but is not the seat of any in- 
flammatory process." It is probable that these epithelial growths 
originate in a downward growth and proliferation of the epidermis and 
external root-sheaths of the hair-follicle, and not from the coil-glands, 
as was supposed by some observers. 

Three cases 1 only of those so far reported have shown any tendency 
to become malignant. It is possible that in these three cases these 
changes were accidents or coincidents such as occasionally occur in 
connection with verruca and other benign growths, but the histological 
structure of the small tumors closely resembles that of true epithe- 
lioma, and, as White suggests, it is quite possible that they all in course 
of time would show a malignant tendency, since most of the cases 
observed so far have been in young subjects. 

Treatment. — The treatment is wholly surgical, with knife or curette. 
Many of the tumors are readily expressed with slight pressure, after 
the skin over them has been incised. Electrolysis is suitable for the 
smaller growths. 

Lymphangioma Tuberosum Multiplex. — These rare growths 
supposedly of lymphatic vessels in the skin have been noted by Hebra 
and Kaposi, Pospelow, 2 Van Harlingen, 3 and other writers. The 
lesions in these several cases were practically identical, from a clinical 
standpoint, with those of multiple benign cystic epithelioma described 
above. By many observers the two diseases are thought to be the 
same clinically and pathologically, but Kaposi and others maintain 
that they are distinct in origin and in structure, stating that sections 
show under the microscope rounded or oval spaces, recognizable as dis- 
tended lymphatic vessels by the characteristic endothelium with which 
they were lined. Kaposi distinguishes these tubercles from all subcu- 
taneous cavernous tumors constituted of new-formed dilated lymphatic 
vessels reaching toward the skin, by the limitation in the former of 
the neoplastic growth to the superior parts of the corium. 

LEUCOKERATOSIS BUCCALIS. 4 

(Leucoplasia, Leucoma, Psoriasis Lingua, Smokers' Patches 
of the Mouth, Buccal Psoriasis, Ichthyosis Linguae, 
Tylosis Lingua, Leucoplakia Buccalis. Ft., Leucoplasie, 
Plaques Blanches de la Bouche.) 

In the year 1868 Bazin described with tolerable accuracy the several 
conditions indicated by the names given above ; and since that date the 
subject has been enriched by a literature contributed by Debove, Kaposi, 
Sigmund, Plumbe, Mauriac, Schwimmer, Ingals, and others. The title 

1 Those of White, loc. cit. ; Jarisch, Die Hautkrankheiten, p. 788 ; and Stelwagon, 
Diseases of the Skin, p. 613. 

2 Vierteljahr., 1879. 

3 Phila. Med. Times, 1881. 

* For full bibliography see Benard, La Pratique Dermatologique, vol. ii., p. 999 ; 
and Butlin, Diseases of the Tongue, London, 1900. 






LEUCOKERATOSIS BUCCALIS. 635 

of these paragraphs is that given by Besnier and Doyon as the least 
misleading and the most descriptive. 

The disease is manifested chiefly in the mouth, by the occurrence on 
the inner faces of the lips and cheeks, and on the dorsum and edges of 
the tongue, of sharply outlined, dull-whitish, slate-colored, or silver- 
whitish points, disks, streaks, bands, ribbons, or patches of an irregular 
shape, either flattened or slightly elevated above the general level of 
the mucous surface. The disease may occur in isolated points or in 
pinhead-sized nodules, discrete or confluent, and in cases grouped, the 
grouping being often in linear arrangements, following the lines indicated 
by the streaks or the strise of similar composition. 

The sites of election of these lesions are : the inner face of the cheek 
in a line following that traced by the conjunction of the teeth of the 
upper and lower jaw when approximated ; the gums above the upper 
canine teeth and lateral incisors; the sulcus beside the upper and lower 
gums in the roof and floor of the mouth ; the dorsum and edges of the 
tongue, where the arrangement is usually in lines along the longitudinal 
axis; and more rarely other parts such as the vaginal and othe^mucous 
membranes which have been involved. 

When closely examined these lesions are found to be made up of a 
hyperkeratinized epithelium, being covered by an adherent and more 
or less dense pellicle, removable only by artificial measures and closely 
applied to the inferior stratum of the mucosa. The lesions are rough 
to the touch, both to the finger of the physician and to the tongue of 
the subjects of the disease, but are, as a rule, not painful, though at 
times annoying by producing a certain degree of stiffness and immobility 
of the parts affected. At times the membrane in the vicinity is reddened 
and tender. 

These lesions are extremely chronic of evolution, requiring months 
and often years for their full development, and resisting in a remarkable 
way the action of topical medicaments. They may be removed without 
recurrence ; or may recur after complete and radical ablation. If 
unmolested and not undergoing resolution (a termination somewhat 
doubtful of occurrence), they usually, by reason of increased density, 
crack or fissure at one or another point, the fissure extending to the 
derma and arousing a local inflammatory process with the production 
of pain and distress. The surface is then prone to exfoliate and ulcer- 
ate, and epithelioma of the mouth may result. 

The proportion of the benign cases to those which result in epithelioma 
is not determined. Every leucokeratosis, however, may prove the initial 
stage of an epithelioma, and the treatment of the former is, therefore, a 
matter of no little consequence. 

The Etiology of these cases is suggested by some of the names given 
above. The disorder occurs almost exclusively in the mouth of men, 
and usually after middle life. Unquestionably, the irritation produced 
by tobacco, whether used in smoking or chewing, and the influence of 
carious teeth or those with sharp edges after fracture irritating the edge 

1 C/". Butlin, Brit. Med. Jour., 1901, ii., p. 61; and Perrin, Annates, 1901, s. 4, ii., 
p. 21 (with bibliography and discussion of the relation of vulvo-anal leucokeratosis to 
kraurosis vulvae). 



636 NEW-GROWTHS. 

of the tongue, are all important. The resemblance of these lesions to 
the mucous patches of syphilis is obvious ; and it is believed that 
syphilis, when not actively efficient in the production of leucokeratosis 
buccalis, may be one of its indirect causes. It is, however, important 
to note that all the symptoms here described occur in persons who have 
never suffered from syphilis ; and such symptoms are in the latter class 
fully as intractable as in others. 

Pathology. — It is not definitely known if the primary change is a 
pure hyperkeratinization of the epithelium or an inflammatory process 
of the papillary layer. The horny layer is hypertrophied, the cells 
retaining their nuclei. In the derma there is always more or less in- 
flammatory infiltration, and often the papillae are partially obliterated. 
Fordyce states that overgrowth and proliferation of the interpapillary 
processes are exceptional. Leloir insists that the epitheliomatous process 
always begins not at the level of the hyperkeratosis of the mucous 
membrane, but below the fissure or other lesion induced by the indura- 
tion of the plaque or streak, indicating, in other words, that the epithe- 
liomatous change is rather an accident than an essential part of the 
process. 

The Diagnosis is chiefly from syphilitic lesions of the mouth, which 
should be recognized, as a rule, by their softness and tendency to ulcer- 
ate, as well by their situation, which is far less distinctive than in the 
case of leucokeratosis of the mouth. A history of infection and of 
symptoms of the disease in other regions of the body w x ould usually 
indicate the nature of the process. 

The only malady likely to be confounded with leucokeratosis of the 
mouth is lichen planus ; and it is important to note that some confusion 
exists on this point in several descriptions of the two diseases. 

In lichen planus of the inside of the lips there may be recognized 
over the tongue, the palate, and other parts, dents, smooth or fissured 
plaques, rings, festoons, linear striae, or disks covered by a silver-whitish 
pellicle. It is clear that the distinction between these and leucokera- 
tosic lesions is in a high degree obscure, and for the present the most 
that can be done is to search with special care for other symptoms of 
disease upon the cutaneous surfaces of the body pointing to either 
lichen planus or to syphilis. 

The Treatment of leucokeratosis of the mouth is first by abstention 
from all local irritants (tobacco ; highly spiced, heated, acetous, and 
iced particles of food and drink), by the care of the teeth, and by the 
employment of soothing sprays or lotions containing potassium chlorate, 
boric acid, balsam of Peru, iodized phenol, myrrh, borolyptol, or muri- 
ated iron. 

Silver nitrate may be applied to any ulcerated or fissured points, 
both in solution and by sweeping the solid crayon over the surface. 
The French make use of the salicylates in the same way. 

Destruction or removal of the lesions may be secured by the employ- 
ment of caustics, chemical or galvano-cauteric ; by erasion with a 
curette ; or by surgical ablation. When practicable, the burr of the 
dental engine may be used after injection of cocaine muriate. Where 
the patches are not too dense and extensive this has generally been 



MYOMA. 637 

productive of good results. Vidal employed a 20 per cent, solution of 
chromic acid. In two instances Ave have secured considerable im- 
provement in the condition by the use of the a>rays. 

Sherwell 1 reports complete removal of the patches by the use of 
undiluted liquor hydrargyri nitratis. The mouth is stuffed with cot- 
ton to protect adjacent parts ; the solution is applied and allowed to 
remain from fifteen to twenty minutes, after which it is neutralized with 
sodium bicarbonate. If necessary, the application may be repeated two 
or three times at intervals. 

Pierce 2 was successful in one case after rubbing into the patches 
pyoktanin-blue, followed immediately with an aqueous solution of 
anilin-oil. The applications were made daily for three months. 

For leucokeratosis of the vulvo-anal region complete excision has 
given the best results. 

The Prognosis is fairly favorable in the case of all subjects of the 
disease who consent to deny themselves absolutely the luxury of tobacco- 
usage in every form, and who can follow a prescribed hygienic and 
medicinal course. For all others there is danger of epithelioma. 

MYOMA. 

(Gr. fivav, muscle.) 

Cutaneous myomata are divided by Besnier 3 into two classes : 
simple myoma, or liomyoma; and dartoic myoma. 

Dartoic Myoma is much more common than is the other form, 
and is of chief interest to the surgeon. It is usually single, though 
occasionally multiple, and occurs most frequently on the mammae, the 
labia majora, the penis, and the scrotum. The tumor develops slowly, 
finally attaining a size varying from that of a small nut to that of an 
orange, and may be sessile or pedunculated. In most cases reported 
pain has been slight or absent, though it was marked in a case reported 
by Virchow. Under the influence of cold and local irritation the tumor 
usually contracts or may show a slow vermicular motion. Some of 
these tumors are composed almost entirely of non-striped muscle- 
fibres, others are mixed with other tissues to form a Fibromyoma, an 
Angiomyoma (Myoma Telangiectodes), or a Lymphangiomyoma. 
Simple Myoma is rare, only twenty cases 4 having been reported. 
Its lesions are usually multiple and occur most frequently on the 
upper extremities, affecting chiefly the extensor surfaces ; but they 
may occur on other parts of the body. They begin as minute round 
or oval macules or papules which develop slowly to the size of a small 

1 Jour. Cutan. Dis., 1899, xvii., p. 185. 

2 Chicago Med. Kecorder, 1897, xii., p. 178. 

3 Annales, 1880, s. 2, i., p. 25 ; and Besnier-Doyon translation of Kaposi, vol. ii., 
p. 346, with reference to all reported cases. 

4 For a resume of all cases reported to date see Crocker, Brit. Jour. Derm., 1897, 
pp. 9 and 47 ; Eoberts, Ibid., 1900, xii., p. 115 ; Morris, Ibid., 1901, xiii., p. 8 (a case 
shown before the London Dermatological Society) ; and Marschalko, Monatshefte, 
1900, xxx., p. 313 (with survey of most of the previously published cases). 



638 NEW-GROWTHS. 

pea or bean, occasionally becoming larger. At first readily effaced with 
the finger, later they become firm and elastic to the touch, are usually 
limited to one or two regions of the body, where they appear in patches 
without definite arrangement or grouping, and are pinkish, reddish, 
or of the color of the normal skin. In the beginning the growths are 
usually insensitive, but in most cases after slow evolution become painful 
on pressure and in some instances they are the seat of paroxysms of 
severe pain which occur spontaneously and at irregular intervals. 
Nearly all the cases reported have been in elderly people and in men. 
Some of the tumors may undergo involution, but usually they tend to 
increase in size and in number. Histological examination shows that 
they are limited to the derma proper, and are composed chiefly of 
unstriped muscle-fibre mixed with some elastic tissue, with a few ves- 
sels and nerves, and are frequently developed about the hair-follicle. 
They are probably derived from the erector pili muscles. 

In a case under observation multiple pinhead- to large bean-sized 
congenital tumors were situated near the sterno-cleido-mastoid muscle 
of a girl nineteen years old. These were exquisitely sensitive to pres- 
sure, were capable of slight vermicular motion when irritated, and 
examination of the largest, after removal, disclosed smooth muscular 
fibres, and, in small proportion, terminal filaments of cutaneous nerves. 

The Diagnosis in well-marked cases is not difficult, but in some 
instances the recognition of the disease must depend upon a micro- 
scopical examination. Myomata have been mistaken for xanthoma 
tuberosum, for keloid, for lymphangioma tuberosum multiplex, and for 
neuro-fibroma. The last-named tumors are painful from the begin- 
ning, and usually develop in the course of a nerve. 

The only successful Treatment is by excision. 

ANGIOMA. 

(Gr. ayyelov, vessel.) 

Angiomata are divided into those composed of blood-vessels and 
those formed of lymphatic vessels. The former are much more fre- 
quent and variable in character. 

Symptoms. — Blood- vascular new-growths occur in three forms: 
nsevus vasculosus, telangiectasis, and angioma cavernosum. 

Naevus Vasculosus (N.evus Flammeus, N^vus Sanguineus; 
Ger., Gefassmal). — This term is limited to those vascular anomalies 
of the skin which are either visible at birth or become developed in a 
brief period thereafter. They commonly occur as irregularly outlined 
or distinctly circumscribed, smooth spots, patches, or maculations, 
varying in color from light red to deep violet and port wine, and are 
either flat or very slightly elevated above the general level of the in- 
tegument. From this type wide variations are noted, in the develop- 
ment of pea-sized papules or tubercles to tumors even of large size ; 
pulsating and aneurismal in character ; spongy or relatively firm ; 
fading or more rarely persistent under pressure ; superficial or deeply 
seated ; venous or arterial in their connections ; single or numerous ; 
and in either case limited to a small area or involving a relatively 



ANGIOMA. 639 

large surface. 1 They are of most common occurrence upon the head, 
but are seen also on the trunk and extremities. Often they are the 
sole lesions of the skin present in a single individual ; in other rarer 
cases they complicate moles, warts, and lymphangiomata. 

The surface of these lesions is usually smooth, though it may be 
rugous. They are generally compressible, losing their habitual color 
when the blood is forcibly pressed out from the loose meshwork of 
vessels of which they are composed, and becoming turgid and deeply 
tinted when the blood is driven into their tissue, as in the face in the 
act of sneezing. 

The course of these lesions varies with their essential character. Of 
the simpler varieties, the larger number increase somewhat in extent 
and development till they have attained a maximum size, and then 
they either persist indefinitely or accomplish a species of involution 
after agglutination of the vascular walls, leaving a whitish, cicatriform, 
occasionally pigmented surface. Others extend indefinitely, involving 
the neighboring mucous surfaces, subcutaneous tissue, and deeper 
structures, forming vast tumors, destructive not only by their tendency 
to extension, but by their mechanical effect. Fortunately, these ex- 
treme developments are rare. Much more commonly vascular nsevi 
furnish the forms known as " port-wine mark " or " claret-stain," 
which awaken no subjective sensations, and are usually of clinical im- 
portance in consequence of the marked disfigurement which they 
produce. 

Occasionally, especially in the case of infants but a few days old, 
phagedena or gangrene will suddenly occur in these patches without 
appreciable cause (probably in consequence of the occurrence of throm- 
bus), and the entire tumor will be removed, the line of demarcation 
of the destructive process being exactly limited to the border of the 
angiomatous tissue. The scar resulting is superficial, and becomes 
smoother in course of time. In this way may occur spontaneous cure 
of nsevi of considerable size existing on the head and genitalia of 
infants. 

Telangiectasis (N^vus Araneus, " Spider Cancer"). — Tel- 
angiectases are acquired dilatations often combined with new forma- 
tion of blood-capillaries, which appear at periods of life other than at 
birth or a few months later ; and are, therefore, distinct from the con- 
genital forms of the disease. They are commonly first observed in 
adult life and occasionally multiply with advancing years. They 
occur in diffuse and localized forms. 

Diffuse, generalized telangiectasis is exceedingly rare. Hillairet and 
Vidal have each observed one such case in individuals of both sexes ; 
the condition being apparently due to systemic disturbance. 

The localized forms are betrayed by the occurrence of flat or slightly 
elevated, pinhead- to pea-sized macules ; diffuse patches ; linear ramifi- 
cations of individual vessels ; or contorted congeries of a plexus of the 
latter, all exhibiting the variations in color of nsevi vasculosi, but 
usually of pinkish or violaceous hue. They are unaccompanied by 

1 Cf. Keport of extensive case by Moller, with reference to the literature of 
naevus giganteus. Archiv, 1903, lxiv., p. 199. # 



640 NEW-GROWTHS. 

subjective sensations, are evidently non- inflammatory in character, and 
are simple or multiple lesions chiefly upon the face, but also upon the 
neck, the back of the hands, the thighs, and other parts of the body. 
They are not rarely observed in connection with other diseases. Thus 
they occur in the vicinity of the lesions of lupus erythematosus, sclero- 
derma, acne rosacea, cicatrices, and about the contour or over the sur- 
face of many malignant tumors. They may, therefore, have either an 
idiopathic or symptomatic character. Osier 1 reports three cases of 
multiple telangiectases in patients who suffered, in common with other 
members of the family, from recurrent epistaxis, and calls attention to 
the frequent development of telangiectases following diseases of the 
liver. 

The term Rosacea, as distinguished from acne rosacea, is employed 
to designate that condition in which the skin, of the face particularly, 
is affected with dilatation of the capillaries. (Consult in this connec- 
tion the chapter on Acne Rosacea.) 

The conditions here described as nsevus vasculosus and telangiectasis 
are displayed in forms which, apart from the question of congenital 
origin, offer the widest differences and the most bizarre combinations. 
The so-called nsevus flammeus, nsevus araneus (spider-cancer), nsevus 
vinosus, " mulberry-," " strawberry-," and "mother-marks " are all 
examples of these combinations. 

The lesions may be congenital. There is no proof that they are 
due to antenatal maternal impressions, though the influence of the 
nervous system in deciding the area of limitation of the congenital 
forms is exceedingly distinct, as, for example, the definition of a port- 
wine mark in the skin-area supplied by one supraorbital nerve. 

Angioma Cavernosum (Tumor Cavernosus). — Cavernous angioma 
is distinguished from the angiomatous lesions described above by the 
peculiarities of its formation. It consists of a dense framework of new- 
formed connective tissue, inclosing loculi or chambers of varying 
capacity, containing blood and communicating not only with each 
other, but with the larger vessels in the vicinity. Whether these 
blood-spaces originate in the fibrous felt-work of the derma which 
later establishes a vascular connection, or in the vessels themselves, or 
whether they are constituted by a mechanical dilatation of such vessels 
in consequence of a new-formed connective tissue in the adventitia, has 
not been determined. According to Virchow, the lesions arise gen- 
erally from coalescence and dilatation of vessels. Other causes are 
explained by the earlier formation of a contracted cicatricial tissue by 
which vascular distortion occurs. (Rindfleisch.) 

Cavernous angiomata are said to be rarely congenital, developing 
soon after birth, and to be both superficial, deep, circumscribed, and 
diffuse. Sometimes they originate from a nsevus or superficial telan- 
giectasis. Often when fully formed they are distinctly encapsulated. 
The diagnosis is between cysts, fibromata, lipomata, and sarcomata. 
The rarity of this affection in derma tological practice may be explained 
by the surgical features of many cases. In five years no instance of 
angioma cavernosum was reported in the statistical tables of the Amer- 
1 Johns Hopkins Hosp. Bull., 1901, xii., p. 333. 



ANGIOMA. 641 

ican Dermatological Association. Post 1 reports a unique case in which 
the tumors were numerous, large, and firm, and recurred after removal. 

Etiology and Pathology. — The causes of the several forms of 
angioma named above are obscure. The symptomatic telangiectases 
are undoubtedly to be explained by obstruction to the circulation occa- 
sioned by the tumor or other lesion to which they are accessory. The 
foundation for the vulgar belief that maternal impressions are respon- 
sible for the so-called " mother's marks " is very slight. The reputed 
resemblance of the latter to various flowers and fruits generally requires 
for its recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation and new 
formation of venous and arterial capillaries in the superior portions of 
the derma, the vessels of the newly formed plexus freely communicat- 
ing with each other. Generally there is a simultaneous new formation 
of connective tissue constituting the framework of the growth, which 
varies considerably in the different forms of the disease. Lobules con- 
stituted of coils of capillary vessels are often separated by it into dis- 
tinct masses. According to Heitzmann, the large spaces of angioma 
cavernosum imitate the structure of the corpora cavernosa of the penis, 
and are filled with venous blood, being separated from each other by 
a scanty fibrous connective tissue. 

Billroth states that the new formation has its origin in the vascular 
network surrounding in basket-like forms the fat-lobules, follicles, and 
glands of the skin. Embryonal, vascular growths spring from these, 
and as they multiply and develop are enforced by proliferation of 
fibrous, connective, and muscular tissue. The color depends largely 
upon the preponderance of arterial or of venous capillaries in the new 
formation. 

Diagnosis. — The ordinary lesions of angioma are readily recognized 
by their color, size, shape, and obvious vascular constituents. Ander- 
son calls attention to the importance of differentiating encephalocele 
due to the failure of ossification of the ethmoid and frontal bones at 
the root of the nose. Operations upon such tumors supposed to be 
angiomatous in character have resulted fatally. Lobulation, great dis- 
tention (when a child is crying), a superficial rather than deep and com- 
plete vascularization of the smooth and glossy skin of the tumor, and 
a double pulsation, all point to frontal encephalocele. 

Treatment. — The treatment of this group of new-growths is, in 
general, limited to a series of local surgical procedures. These opera- 
tions all have in view either the destruction of the new-growth or the 
artificial production of an inflammation, in order to obliterate, to an 
extent sufficient to interfere with the transmission of the blood-current, 
the lumen of the capillaries of which the neoplasm is composed. 

First among these methods, for superficial growths in which the 
vessels are small, is electrolysis. One or a set of several fine cambric 
needles, with their points at the same plane, are connected with the 
negative pole of an ordinary zinc and carbon battery of ten to twelve 
cells. The points of the needles are passed quickly into the tissues 
1 Jour. Cutan. Dis., 1903, xxi., p. 498, 
41 



642 NEW-GROWTHS. 

and there held for a period of between ten and thirty seconds, accord- 
ing to the effect produced after completion of the circuit, with a cur- 
rent of from one to two milliamperes. The new-growth is thus 
blanched in the vicinity of the needles, this effect disappearing in the 
course of a few moments. 

In about three weeks the curative result of the operation becomes 
apparent. According to Fox/ of New York, the objections are that 
the operation is sometimes painful and tedious, and may occasionally 
result in the production of suppuration, superficial sloughs, minute 
keloid-like elevations, vascular nodules, depressed scars, or superficial 
ulcers. In scores of cases, however, there is no production of re- 
sults worse than the original disfigurement. Usually the success is 
complete. 

Phototherapy has proved effective in a small number of cases of 
vascular nsevi. The method is preferable to electrolysis when a con- 
siderable area is involved, or when the individual vessels supplying or 
composing the nsevus are not distinctly visible. We have secured great 
improvement with the treatment in two extensive cases of this type. 

The method of Sherwell 2 is by multiple puncture with a set of fine 
needles in a holder similar to that described above. These are dipped 
in a 25 to 50 per cent, solution of chromic acid, and then made to 
penetrate the part to be attacked. The bleeding is readily arrested 
by pressure, and then the patch is covered with several layers of flexile 
collodion. This procedure is of value in circumscribed patches of super- 
ficial character and relatively limited area. By it one can succeed in 
removing port-wine marks with the result of producing a somewhat 
irregular cicatriform tissue much less disfiguring than the original 
blemish. 

Squire's operation is done upon previously frozen patches with the 
aid of an instrument which destroys the vessels by making numerous 
crossed and closely spaced linear incisions, parallel to each other and 
in a plane obliquely directed to that of the integument. Here also 
bleeding is arrested by pressure, exerted before the circulation is re- 
stored. The operation has been, in hands other than his own, attended 
at times with unsatisfactory results. 

Sodium ethylate, a compound in which the radical ethyl in ethylic 
alcohol is united with sodium, is a caustic recommended by Richard- 
son 3 in the treatment of nsevus. It is applied by means of a brass 
rod. A first application usually results in the formation of a dense 
crust under which the nrevus contracts ; and repeated applications are 
made at intervals of a few days till the desired result is obtained. 
The sodium ethylate should be pure, and the crusts should not be dis- 
turbed till they fall spontaneously. In one case there was a persistent 
redness of the resulting scar that was decidedly open to objection. 

Other methods employed are the ligature when practicable ; puncture 
with incandescent needles; topical application of caustics other than 
those named above, such as potassium hydroxide, nitric and carbolic 

1 N. Y. Med. Kecord, 1882, xxi., p. 188. 

2 Arch, of Derm., 1879, v., p. 354. 

3 Lancet, 1878, ii., p. 654. 



ANGIOMA. 643 

acids, and corrosive sublimate ; and total excision, the latter being 
practicable in relatively small growths. Larger growths also can be 
removed and the surface covered with skin-grafts. The galvano- 
cautery and the thermo-cautery are both valuable in the destruction of 
capillaries. For telangiectasis and nsevi no larger than a pea the 
Paquelin knife is an efficient resort. The old method of multiple 
vaccination about and upon the involved area is sometimes followed by 
good results, and whether in consequence of the retraction of tissue 
under the influence of the inflammation excited, or of the destructive 
results of the suppuration induced, or of an indefinite caustic effect, is 
not clear. 

These results may be partly imitated by the induction of superficial 
pustulation and suppuration through the medium of tartar emetic and 
croton-oil, methods which should be considered clumsy in the light of 
recent successes obtained by more manageable expedients. 

Injections with carbolic acid and ferric chloride in a few cases have 
been followed by fatal results, but are at times successful. 

Coombs 1 has modified somewhat the method most in vogue, by 
passing fine silver wires through naevus-growths, and connecting the 
extremities with a Bun sen battery. When the wires are heated the 
circuit is broken, and the ends of the wires are disconnected from the 
battery and united to each other, being left in situ and covered with 
lint and plaster. The current can then be passed repeatedly without 
reinsertion of the wires, and the latter need be withdrawn only when 
the cure is complete. 

The Treatment of angioma cavernosum requires surgical interfer- 
ence. 

The Prognosis in any case of angioma rests upon the method of 
treatment adopted for its removal. In the larger number of cases the 
lesions, having attained a maximum development, persist without 
further pathological change, constituting a deformity rather than a 
disease. Physiological alterations in the color of such lesions occur 
under the influence of changes in the circulation. 

ANGIOMA SERPIGINOSUM. 

(Infective Angioma, N^vus Lupus.) 

This disease has been described and figured by Hutchinson, 2 Jamie- 
son, Lassar, Joy, White, and others. It is one of the rarer affections 
of the integument. 

Symptoms. — The elements of each group of lesions are bright- 
reddish puncta, resembling grains of Cayenne-pepper, arranged in oval 
or circular rings which are definitely outlined, and are a centimetre or 
more in diameter. The " infective satellites " are outlying points or 
patches where the disease is spreading. This extension is usually at 
the outer border of one of the annular groups of lesions. The color 
varies from a light- to a deep-reddish hue or purple ; tints which are 
due to the vascularity of individual lesions. The color can at times 
be made to disappear on pressure. 

1 Lancet, 1881. 

2 Arch, of Surgery, 1889, i., p. 289, Plate IX. 



644 NEW-GROWTHS. 

The parts chiefly affected are the shoulder, the leg, the elbow, the 
ear, the arm, the hand, and the chest. The disease may occur in infancy 
or adult years. Its evolution is slow, and usually unproductive of 
subjective sensations. Occasionally the tufts of dilated capillaries 
which constitute the reddish points are not grouped in a circinate or 
other special arrangement, but simply irregularly distributed over the 
affected surface. 

Etiology. — The cause of the disease is unknown. In a case under 
our observation in a female infant the lesions developed as a sequence of 
a congenital naevus of the vulva. Hutchinson has made a similar obser- 
vation. The affection has been noted more often among male patients. 
One case is supposed to have originated in violent muscular exercise. 

Pathology. — The disease, being at first but obscurely understood, 
was until recently supposed to be one of the several expressions of 
lupus and was for that reason assigned one of the names given above. 
Examination of tissue removed from a patient whose case was fully 
reported by White, 1 which was in all points typical, reported upon 
also by Darier, Councilman, and Bowen, indicates that the disease is 
an angiosarcoma. Darier describes it as sarcome angioplastique r&ticule. 
The corium was found well filled with small-cell infiltrations, and these 
cells had an epithelioid nucleus. There were abundant proliferation of 
the endothelium and perithelium and a new formation of vessels. 

Diagnosis. — The disease is to be recognized by its vascular puncta 
and by their special tendency to grouping and extension through a 
serpiginous process never seen in simple telangiectases, nor in common 
forms of mevus vascularis. 

The Treatment is by surgical ablation or destructive cauterization. 

LYMPHANGIOMA. 

In the present state of knowledge on this subject it is not always 
possible to draw sharp dividing-lines between lymphatic new-growths 
on the one side and simple lymphangiectasis on the other. It is prob- 
able that the two processes often are associated. 2 

Lymphangiectasis, uncomplicated by growth of new vessels, may 
occur in the superficial or deep lymphatics. When superficial, pinhead- 
to pea-sized, isolated or grouped vesicles form which have the color of 
the normal skin, which disappear temporarily under pressure, and which 
do not break easily, but on rupture give exit to a continuous or inter- 
mittent flow of lymphatic fluid. Elliott 3 describes a case of this kind 
in which the vesicles bordered old scar-tissue and were seemingly iden- 
tical in character with the lesions of lymphangioma circumscriptum, but 
histological examination showed them to be formed by simple dilatation 
of the lymphatic capillaries, due probably to mechanical obstruction. 

Lymphangiectasis of the deeper vessels often produces no change 
visible on the skin, and can then only be recognized by palpation, or it 

1 Jour. Cutan. Dis., 1894, xii., p. 505. 

2 For review of literature of the subject, consult Francis, Brit. Jour. Derm., 1893, 
v., p. 65 : and Koberts, Ibid., 1897, ix., 309. 

3 Jour. Cutan. Dis., 1894, xii., p. 137. 



LYMPHANGIOMA. 645 

may be displayed in raised, irregular cords, or in chains of nodules. 
Following injuries or inflammation it may be acute, but usually it is 
chronic, and occurs most frequently on the lower extremities and in 
parts in which the return current of the circulation is in some way 
impeded. The skin may become the seat of soft nodules which may 
rupture and form lymphatic fistules ; but more frequently the greatest 
changes occur in the deeper structures, resulting in elephantiasis, in 
phlegmon, or in lesions of periosteum and bone, the skin of the affected 
region being cedematous, infiltrated, ulcerating, or cicatricial. 

Simple Lymphangioma may occur upon any part of the body in 
the form of circumscribed, elastic tumors made up of enlarged lym- 
phatics which are the result partly of dilatation of previously existing 
vessels and partly of new-formations. The skin over such tumors 
may be unchanged or it may be reddened and thickened. In more 
extensive cases there is hypertrophy of the surrounding tissues as in 
deep-seated lymphangiectasis. Many of the diffuse forms of lymphan- 
gioma constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymph angiectatic a or Pachydermia Lymphang- 
iectatica. These tumors often contain large lymph-filled sacs or 
lacunse, enveloped in hypertrophied muscular and connective tissue, 
and an cedematous integument. Some of the elephantiasic deformities 
of this character are fully as enormous as the extreme distortions of 
elephantiasis proper. Upon the tongue the condition is called Mic- 
roglossia, and upon the lips Macrochilia. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions, where the lymphatic vessels in the 
lymphatic glands dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
described elsewhere. 

Simple lymphangiomata may be congenital. 1 Their cause is un- 
known. It is supposed that they are produced by toxic or other irri- 
tating influences. They are often the seat of a recurrent, circumscribed 
inflammation of erysipelatous type. Anatomically the lesions are 
found to consist of greatly developed lymphatic vessels and spaces, 
lined with epithelium and enveloped in small-celled connective tissue- 
stroma. The treatment, of the larger lesions only is surgical. 

Cystic Lymphangioma belongs to the domain of surgery. It 
occurs in the form of multilocular cysts, usually congenital in origin 
and most frequently situated in the neck. 



Lymphangioma Circumscriptum. 

(Lymphangioma Cavernosum, Lymphangiectodes, Lymphan- 
gioma Capillare Yaricosum, Lupus Lymphaticus. 
jPr., Angiome Cystique.) 

This is practically the only form of lymphangioma entitled to spe- 
cial consideration by the dermatologist. It is a rare form of skin-dis- 

1 Volmer (Archiv, 1903, lxv., p. 343) reports a rare case, with illustrations, his- 
tology, and bibliography. 



646 NEW-GROWTHS. 

ease and is illustrated well in the case reported by Morris. 1 Cases 
have been reported by Torok, 2 White, Francis/ Hartzell, Elliot, Gil- 
christ, Brocq and Bernard, 4 Schnabel, 5 and others. 

Symptoms. — The characteristic lesions are small, deep-seated ves- 
icles generally described as resembling frog's spawn. They are usu- 
ally closely crowded in irregularly shaped groups from eight to twenty 
millimetres in diameter with normal skin between. These groups have 
no regular arrangement or distribution. There are sometimes a few 
scattered vesicles about or between the borders of the groups which 
may coalesce to form new patches. There are usually several of these 
groups, but they are confined, as a rule, to one small region of the 
body. The most common sites, according to Francis, Avho has collated 
reports of twenty-eight cases, are on the upper parts of the extremities. 
In a large majority of the cases reported the lesions occurred on the 
left side of the body. 

The vesicles are deep-seated with thick walls, and vary in size from 
that of a pinhead to that of a small pea. The newer and scattered 
vesicles may be colorless or have a yellowish or pinkish tinge, but the 
skin over the older lesions may hypertrophy and produce growths that 
are easily mistaken for warts, and may even result in decided warty 
projections. Other lesions may be more or less covered with telangi- 
ectases and vascular dots or tufts which may be present to such an ex- 
tent as to obscure the primary vesicle-formation. When punctured the 
lesions give exit to clear, colorless fluid, which at times may be tinged 
with blood, the result of hemorrhage into the vesicle. 

In some cases the lesions and skin about them become the seat of a 
recurrent inflammation of erysipelatous type, 6 such as not infrequently 
complicates other forms of lymphangioma. Probably as a result of 
these attacks of inflammation there are often infiltration, thickening, 
and even true hypertrophy of the deeper layers of the skin, forming a 
sort of local elephantiasis. 

The disease in most cases reported began in early childhood and 
developed very slowly, often remaining stationary for years. In but 
one case has spontaneous involution been reported. 

Etiology. — As the disease usually makes its appearance in infancy 
or early childhood, it is probable that its origin is due to some con- 
genital defect. It has appeared a number of times in connection with 
nsevi. It has followed surgical operations, bordering the scars pro- 
duced by the operator; it is possible that such cases are simple lymph- 
angiectases of the capillary vessels due to blocking of the larger 
channels by the scar-tissue. 

Pathology. — The vesicles, or cysts, are found on section to be situ- 
ated in the upper part of the corium. These cysts are shown to have 
an endothelial lining and undoubtedly are dilated or newly formed 

1 Internat. Atlas, 1889, No. 1. 

2 Monatshefte, 1892, xiv., p. 169, with critical review of previourly published cases. 

3 Brit. Jour. Derm., 1893, with review of literature. 

4 Annales, 1898 (full discussion of the subject, with review of literature). 

5 Archiv, 1901, lvi., p. 177, with histology and references. 

6 Cf. White's report, Jour. Cutan. Dis., 1894, xii., p. 47 ; also Bowen's article in 
Twentieth Century Practice, vol. v., p. 687. 



XERODERMA PIGMENTOSUM. 647 

lymph-capillaries. Immediately about the cysts and dilated lymphatics 
in an early uncomplicated lesion Bowen found considerable infiltration 
of round cells, but no other changes in the corium, while the epidermis 
was slightly thinned. In older lesions there is hypertrophy of the 
epidermal layers, and sometimes of the deeper parts of the corium. 
In other cases there are more or less dilatation and apparently new 
growth of the blood-capillaries. This change in the blood-vessels may 
be slight or so marked as to form the chief feature of the disease both 
clinically and pathologically. In consequence, confusing reports have 
been made by different observers regarding the structure and origin of 
these growths, many of which seem entitled to the name of hemato- 
lymphangioma. 

Treatment. — The treatment is surgical. The growth may be re- 
moved by excision or with the cautery. Electrolysis has been of service 
in some cases and should be given further trial. In several instances 
the lesions have recurred after complete removal. 

XERODERMA PIGMENTOSUM. 

(Gr. gepoc, hard; Sep/na, the skin.) 

(Angioma Pigmentosum et Atrophicum; Atrophoderma Pig- 
mentosum, Dermatosis Kaposi, Melanosis Lenticularis 
Progressiva, Lioderma Essentialis cum Melanosi et Tel- 
angiectasia, Lentigo Maligna. Ft., Epitheliomatose 
pigmentaire.) 

Xeroderma pigmentosum is a rare disease, described by different 
authors under the several titles given above, but most often designated 
by the name given as the title of this section. It was recognized first 
and described by Kaposi, in 1863, 1 on the basis of two cases seen by 
the elder Hebra and himself, this number being increased by two in 
the year 1870. Since then more than one hundred cases have been 
placed on record in different countries, and about a score in America 
by Taylor, Duhring, White, Brjnson, Drayton, Hutchins, Bowen, and 
others, including ourselves. Eecently we have studied the disease in 
three children of one family, the patients being the subject of the 
illustrations of the disease in the present edition of this treatise. 

Symptoms. — The disease begins most often in early life, from the 
third or the fifth month to the close of the first year, though it has been 
observed first in adults and even at an advanced age. Some doubt, 
however, exists as to the occurrence of classical features of the malady 
in the cases developing at these later periods. 

The special stigmata of xeroderma pigmentosum are its symptom- 
groups, any one of which is encountered not rarely in other diseases, 

1 Bibliography: Kaposi, Wien. med. Wchnschrft., 1885, p. 1334; Ibid., Twentieth 
Century Practice, vol. v., p. 727; Lukasievicsz, Archiv, 1895, xxxiii., p. 37 (resume of 
seventy-three cases, and bibliography) ; Kreibich, Archiv, 1901, lvii., p. 123; Monthus, 
Annales, 1902, s. 4, iii., p. 673; Lowenbaeh, Mracek's Handbuch, p. 240 (with full 
bibliography) ; Crocker, Diseases of the Skin, p. 681 ; Herkheimer u. Hildebrand, 
Munch, med Wchnschrft., 1900, xlviii., p. 1099 (full abstr. in Brit. Jour. Derm., 1901, 
xiii., p. 66). 



648 NEW-GROWTHS. 

but the coniplexus of which is scarcely to be seen in any other affec- 
tion, and in particular at an early period of life. The term, senilitas 
precox, has been applied aptly to the condition of the young subjects 
of the disorder. An analysis of the phenomena presented in a well- 
marked case shows that pigmentation, atrophy, telangiectasis, and new- 
growth development coexist. 

At the outset, the mothers of children and some observant phy- 
sicians have seen an erythematous redness, diffuse or in circumscribed 
maculae over the regions later characteristically involved. More often 
the first signs of the disease are visible in a well-marked freckling of 
the skin, the lentigines scarcely if at all differing from those resulting 
from exposure to the light in persons subject to that form of pigmenta- 
tion. This freckling, or pigmentation, in almost every instance involves 
the exposed surfaces of the body, more particularly the face, neck, 
upper chest as far as the third rib, the hands, the forearms from the 
upper third as far as the finger-tips, including to a minor extent the 
flexor aspect of the arms and the palms. In our little patients there 
was a distinct triangulation of pigmentation, the apex of the triangle 
below extending down the back nearly to the sacrum. Occasionally 
the thighs, the legs, the scalp, the sub-ungual spaces, the dorsa of the 
foot, the trunk, and buttocks may likewise be involved. 

The patients are commonly of blond type, with reddish or light- 
tinted hair and blue or lightly pigmented irides ; in short, of the class 
chiefly disposed to freckling. The pigmentations in these cases differ 
as to hue with the age of the patient and the severity of the disease, 
the color ranging from a light fawn-yellow to a deep chocolate-brown. 
The lentigines may be isolated, as is the rule ; or be fused in areas of 
one or several centimetres diameter. 

Interspersed among the lentigines are equally characteristic whitish 
atrophic spots, usually less pronounced than the lesions described above, 
which may be isolated or coalesce into cicatriform patches. When 
sparse, they are somewhat lucent, slightly wrinkled, smooth, or cov- 
ered with micaceous scales. They may precede the occurrence of the 
pigmentations or follow the latter, or even follow the development of 
the telangiectases described below. Crocker ascribes to these atrophic 
areas the production of ectropion, which is a common feature of many 
cases ; but in our experience the ectropion results from epitheliomatous 
infiltration of the lower lids, precisely as in epitheliomatosis of adults. 

The telangiectases, which are equally commoa and characteristic of 
the disease, may be punctate or stellate ; they are usually fine and con- 
spicuous by contrast with the pigmented skin in which they develop, 
though they may result in minute pinhead-sized tumors of the skin 
not rarely observed on the trunk of men and women of advanced 
years. They may be few or numerous, and are less conspicuous as a 
rule on the surfaces covered with the clothing than elsewhere in the 
regions exposed to the light. 

The new-growths visible in the victims of the disease vary greatly 
in type, but we believe that all are epitheliomatous in character, the 
different clinical features described by observers not suggesting a wider 
variation than can be determined in any study of the clinical appear- 



XERODERMA PIGMENTOSUM. 649 

ances of epithelioma in the skin of persons of advanced years, including 
the lesions seen in that class of subjects described as verrucous, papil- 
lary, discoid, fungating, deep-seated, rodent ulcer, etc. 

Thus, for example, in xeroderma pigmentosum there may be pea- 
sized or larger, flattened or pointed warty growths, irregularly dissemi- 
nated among the lentigines, or conspicuously developing at isolated 
points, such as the back of the hand or in front of one ear. In other 
cases there is a distinct circumscribed epitheliomatous infiltration not 
productive of a tumor, cases of the sort referred to above where ectro- 
pion ensues precisely as in the case of the aged person with carcinoma 
of the tissues in or near the lower lid. 

The other symptoms of xeroderma pigmentosum are related more or 
less closely to the chief lesions described above. There may be open 
or crusted ulcerations resulting from circumscribed epitheliomatosis. 
In one of our patients, a boy four years of age," a lesion developed in 
the tragus of one ear which might serve as a classical illustration of 
the " rodent ulcer " of English writers. Healing of such ulcers may 
result further in deforming cicatrization. Papillomatous tumors, devel- 
oping from cicatrices or directly from freckle-like lesions, may assume 
eventually epitheliomatous characters. Keratitis is exceedingly com- 
mon, and this in the early periods of the disorder accompanied by 
photophobia, profuse semipurulent lachrymation, and, according to 
Crocker, producing extension of the disease by the flow of the secretion 
over the cheeks. Corneal opacities, sufficient to obstruct vision even 
in the very young, occur to a grave extent. A profuse catarrhal dis- 
charge from the nose, with extension of the disease to the Schneiderian 
membrane and also to the inner faces of the lips and buccal cavity, 
may result. The scalp may be free, or the seat of pityriasic scaling or 
of lentigines. Sensation and perspiration may be impaired to a varying 
extent. Often, as the disease progresses, a characteristic thinning of 
the affected integument occurs, producing the so-called parchment-skin. 

In very young subjects the partially blind patient has an apathetic 
expression and listless demeanor which are highly characteristic. 

Etiology. — The cause of the disease is unknown, but the records 
indicate clearly that in many cases there is a strongly marked family 
predisposition to the disease, not merely because of the frequency with 
which several members of one family have been affected, but also 
because of the consanguinity of a few families with children similarly 
attacked. The disease is represented equally in the two sexes : many 
brothers and sisters of affected children are free from the disease. 
Beginning for the most part in the first year of life, a few senile 
instances have been reported in which the earliest symptoms were 
declared at an advanced age. The influence of light upon the develop- 
ment of the disease in susceptible subjects has been pronounced effec- 
tive by several authors, and while it is true that, as in one of our cases, 
the lower limbs and trunk, as well as the dorsa of the feet, were in- 
volved, the preponderance of testimony decidedly points, in the victims 
of the disorder, to an extreme susceptibility of the skin to the action 
of sunlight, an agency by no means set aside when the light clothing 
of many young subjects envelops the skin. 



650 NEW-GROWTHS. 

Pathology, — The disease seems to be a cutaneous metamorphosis, 
the primary factor in which is less a primary neurosis, as has been 
taught, than a special susceptibility to the action of the light-rays, 
a fact declared in the well-nigh invariable ocular symptoms developed 
in the subjects of the disease. Whether the morbid process is primarily 
degenerative, or is rather, as the facts tend to show, at the outset 
reactive in the line of erythematous redness followed by degenerative 
changes, remains to be seen. 

The tumors and warty growths developed by the course of the dis- 
ease have been examined repeatedly in section with findings variously 
interpreted. Okamura recognized an oligocythemia and leukocytosis 
in Kaposi's cases ; Crocker, Vidal, Taylor, and Kreibich describe prac- 
tically the same condition, though variously interpreted by them — viz., 
epitheliomatous nests, aggregations of long branching cylinders enclosing 
epithelial cells (" tubular " type, of cancer), and, according to Pollitzer, 
" mixed elements," sarcomatous, myxomatous, sarco-carcinomatous, 
granulomatous, etc. There is general agreement as to the obvious fact 
that the morbid process in all the new-growths is practically an epithe- 
liomatosis, a fact strongly emphasized when Quinquaud demonstrated 
the nature of his classical cases before the International Congress in 
Paris, in the year 1889. 

Diagnosis. — Xeroderma pigmentosum is so pronounced in its feat- 
ures that it is seldom an error is made in its recognition. The early 
date of its onset for the most of cases, the combination of pigmentation, 
telangiectasis, atrophic patches, and the development in the child's skin 
of warty growths, are all significant. The pigmented, atrophic, and 
occasionally vascularized tissue of scleroderma might possibly be mis- 
taken for the disease under consideration, but the leather-like condition 
of the integument in scleroderma, its pigmentation in irregular areas 
(rather than in macular lesions suggesting freckles), its limitation to 
definite areas other than those exposed to the light, and in the circum- 
scribed types its frequent development in the regions supplied by cuta- 
neous nerves — all these are significant. 

Treatment. — Up to the present time, treatment of the disease has 
proved unavailing. Internally, cod-liver oil, tonics, the salts of iodine, 
and arsenic have all been employed. Crocker lays stress upon active 
and prompt surgical treatment of the ocular lesions and epitheliomatous 
growths after their development either as tumors or ulcers. 

Little stress has been laid upon the hygienic management of these 
cases, which we have found of high value. Our patients improved 
greatly under hospital care. We employed the #-ray with excellent 
results in the treatment of several of the epitheliomatous ulcers, which 
speedily went on to repair under the influence of the ray. At the 
same time, seeing that in cases radiotherapy has produced both pig- 
mentation, telangiectasis, and atrophy, it would appear on a priori 
grounds an inexpedient method for adoption in these conditions. 

Prognosis. — The outlook for the majority of cases is exceedingly 
grave, most patients eventually perishing from the immediate or remote 
results of cancerous changes. Two of Crocker's patients lived for nineteen 
years ; another (supposed " senile " case) suffered for forty years. Pre- 



BHINOSCLEROMA. 651 

cocity in wart- and tumor-development is said not to indicate special 
gravity for the future. 



RHINOSCLEROMA. 1 

(Gr. pig, or piv } the nose, and CK?iT]p6g, hard.) 

Symptoms. — A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, has been obtained from a study of some 
one hundred cases observed by these and other authors. The follow- 
ing is a concise description of the malady as thus presented. 

The disease commonly begins in the septum or a single ala of the 
nose, without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 
are flat patches, or elevated and circumscribed nodules, papules, and 
tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or by 
a light or dark-red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses the 
alse become enlarged, flattened, and so indurated that they cannot be 
pressed together, while respiration may be impeded by stenosis of the 
nares. The process may extend to the neighboring parts, involving 
thus the upper and lower lips, gums, velum, epiglottis, larynx, trachea, 
and jaws, the teeth meanwhile falling from their sockets and the soft 
palate becoming in some cases perforated. Involution of the process 
has not been observed, and the lesions do not degenerate by ulceration. 
Max Zeissl, 2 however, reports a case in which there w r as ulcerative 
destruction of the entire left nostril, as well as of the tip and right 
ala of the nose. Occasionally superficial excoriations have occurred, 
but very rarely a diminution in the consistency of the mass. The dis- 
ease pursues a chronic course, requiring years for its development ; and 
though the affected parts are painful on pressure they are otherwise 
not the seat of subjective sensation. 

Etiology and Pathology. — The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and in 
individuals of both sexes, free from syphilitic, strumous, tubercular, 
and other cachexias. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium and its papillary layers with small, 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to small-cell sarcoma, inasmuch as 
Mikulicz, Geber. and Billroth have seen some of the elements of the 
neoplasm undergoing the osseous transformation common in sarcomatous 
tumors. 

In 1882, however, A. von Frisch, after examining tissue removed 
from lesions of rhinoscleroma in twelve patients, found in the cells 

1 For bibliography see Marschalko, Arehiv, 1900, liii., p. 163, and liv., p. 235 (a 
histological and bacteriological study of two cases with full review of subject) ; and 
Castex, La Pratique Dermatologique, vol. iv., p. 187. 

2 Wien. med. Wchnschrift,, 1880, p. 621. 



652 NEW-GROWTHS. 

and between them in the interpapillary fissures of the connective tissue 
bacteria distinctly rod-shaped, one and one-half times longer than 
broad. These germs were successfully cultivated, but experimental 
inoculations with culture-fluids thus obtained were negative in results. 
Dreschfield 1 found in sections of tissue obtained from a patient of 
Payne's numerous bacilli less slender and smaller than those occurring 
in tuberculosis and with slightly thickened extremities. These were 
unlike those exhibited at the Berlin Congress by Paltauf, who con- 
siders them closely related to Friedlander's pneumococcus. Barduzzi, 
Pellizari, Cornil, Alvarez, Lustgarten, and others have added to the 
evidence in favor of the parasitic nature of the disease. 

The bacilli are found encapsulated in a colloid-like substance and in 
series of two and fours. They occur in the lymphatic ganglia, in the 
giant-cells of the neoplasm, and in protoplasmic masses corresponding 
to these or to their degenerate nuclei. Pawlowsky, of Kieff, in 1890, 
demonstrated that the bacilli of the disease are pathogenic for the 
lower animals. Besnier and Doyon, however, pointing to the limi- 
tation of the disease to Austria, reject a parasitic origin for the disease. 
Mibelli, who has given the subject careful study, found two kinds of 
cells characteristic of the process : one a dropsical and the other a 
colloid cell. He thinks these types are the result not of cell-degenera- 
tion, but of the presence of zooglea, a mucous substance produced by 
the bacilli. 

Diagnosis. — The disease can hardly be mistaken for another in con- 
sequence of its situation, the disfigurement it occasions, the ivory-like 
elasticity and induration of the affected parts, and the rarity of ulcera- 
tive degeneration. As distinguished from syphilis, it is known to be 
unaffected by specific medication. Since rhinoscleroma, however, has 
been by some writers assumed to be a form of syphilis, it is need- 
ful to distinguish clearly between the two. But as in the former 
affection there is rarely softening of the ivory-like induration, much 
less ulceration, which is common in syphilitic gummata, the distinction 
is tolerably clear. From the variety of acne rosacea of the nose known 
as rhinophyma, rhinoscleroma is readily differentiated by the softness 
and compressibility of the acneiform affection and its evident vascular 
and glandular composition. 

The ulcerations of epithelioma have a more circular outline, a more 
elevated edge, and occur in persons of a more advanced age. Keloid, 
if found in the situation of rhinoscleroma, does not ulcerate. 

Treatment. — The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 
the nares, where there is actual or threatened nasal occlusion, by means 
of laminaria and compressed sponge. Both excision by the knife and 
destruction by caustics have been found to secure merely temporary 
benefit, as the growth is reproduced with rapidity. 

Prognosis. — The future of the patient is grave. The disease not 
only persists and recurs after operative interference, but also may 
endanger life by obstruction of the nostrils. ZeissPs case proved fatal 
ten years after the disease first appeared. 

1 Brit Med. Jour., 1885, ii., p. 837. 



TUBERCULOSIS CUTIS. 653 



TUBERCULOSIS CUTIS. 

Tuberculosis is erne of the most common, formidable, and destruc- 
tive of the great scourges of the human family. It may attack either 
primarily or secondarily any organ or tissue of the body. The skin 
is not rarely the seat of its ravages, and when extensively involved the 
results are in the highest degree disfiguring and repulsive. 

The consequences of tuberculous invasion of the skin are usually 
declared early in life, because in those periods the skin is most easily 
invaded, and also because at these ages the habits and environments of 
the individual are conducive to the occurrence of the accident. Tuber- 
culosis of the skin may be the result of general infection in the body ; 
or may, on the other hand, be the starting-point of such infection. In 
either event the disease is always originally acquired by infection and 
not by inheritance. Children are rarely, if ever, born tuberculous. 
The coincidence of several members of one family exhibiting evidences 
of the disease is most readily explicable by the opportunities for infec- 
tive accidents furnished in such families. 

In the pages which follow no attempt is made to revert to the 
remarkable and instructive history of the gradual acquisitions of science 
on the subject of this disease. Neither within these limits is it desir- 
able to indicate the several conditions which in their relations to this 
subject have been confused in the past, and the names of which have 
served as titles for chapters on cutaneous disorders. It will be sufficient 
if the results obtained from the vast and valuable labors of the patholo- 
gists and clinicians of the last decade be concisely set forth with a view 
to the simplest systematic conception of the subject. 1 

Symptoms. — The generally recognized clinical forms of cutaneous 
tuberculosis are: (1) lupus vulgaris; (2) tuberculosis verrucosa; (3) 
tuberculosis cutis orificialis ; (4) scrofuloderma. 2 

1. Lupus Vulgaris. 

(Lat. lupus, a wolf. ) 

The symptoms of lupus vulgaris are both numerous and diverse, a 
fact which may account for the many names which have been applied 
to its different manifestations, and which with few exceptions are 
descriptive merely of certain external features. 

The lupous infiltrate may be limited to small areas or diffused over 
an entire region of the body. It may be first apparent in pinhead- ta 
bean-sized flattened maculations (Lupus Maculosus, Lupus Pla- 
nus), from which later may be developed papules, tubercles, or nodules 
of equal or somewhat greater size, rising above the general level of the 

1 In the preparation of this chapter valuable aid has been rendered by the symposium 
on the subject prepared at the request of the Council of the American Dermatol ogical 
Association, by James C. White, of Boston ; John T. Bowen, .of Boston ; and George 
Henry Fox, of New York. Boston, 1892. 

2 Lichen scrofulosorum and erythema induratum are classed as diseases probably 
tubercular. The disorders generally described as tuberculides, paratuberculoses, etc., 
are considered in a subsequent section. 



654 



NEW-GROWTHS. 



skin and often perceptible within its mass by palpation (Lupus 
Nodosus; Lupus Tuberculatum, Elevatus, Tumidus, Non-exe- 
dens, non-ulcerosus). 

As in syphilis in the course of which, though almost every one of 
the elementary lesions of the skin may be developed, there is a dis- 
tinct predominance of the papule and tubercle, so in lupus vulgaris 
the type of the disorder is shown in the lupous nodule, the " lupoma," 
as it is by some authors designated. 

This dull-reddish, purplish-shaded lesion, scarcely as large as half 
a pea, may be the predominant symptom of a lupous patch for a period 
of from ten to twenty years and even more. It is of a softish, almost 
boggy consistency, yielding when pressed upon firmly with a blunt- 
pointed probe and readily penetrated by a sharper instrument. The 
English compare its contents with apple-jelly. 



Fig. 70. 




Lupus vulgaris. 

The changes within, about, and beneath these lesions furnish prac- 
tically the clinical pictures of lupus vulgaris. Thus there may be 
extensive oedema, thickening, hypertrophy, hyperplasia (bouffissure), 
pachydermia, even telangiectasis, and an accompanying lymphangitis 
or lymphadenitis (Lupus Hypertrophicus, Papillosus, (Edema- 
tosus, Elephantiaticus, Tumidus, Exuberans, etc.). In many of 
these cases the prominent symptom which has suggested these names 
to the older writers is in fact a simple inflammatory swelling, clue only 
indirectly to the lupoid involvement of the skin, a fact which can be 
recognized after any efficient treatment of an extensive plaque of lupus 
of the face, the subsidence of the swelling being one of the most con- 
spicuous of the immediate results of the treatment. 



PLATE XXIII. 



Fig. 1. 




Lupus Hypertrophieus. 



Fig. 2. 




Lupus Vulgaris of the Leg. 



TUBERCULOSIS CUTIS 655 

Involution of the lupoma, or of tissue infiltrated with lupoid cells, 
occurs by resorption of that material, by fibroid metamorphosis, and 
by ulceration. These several changes separately or together furnish 
other clinical pictures of the disease. Thus the lupus-lesion or patch 
may furnish scales, whitish, dirty, yellowish brown, or even glistening, 
the epidermis above and about becoming wrinkled. This process may 
be central or peripheral as respects patch or lesion, leaving eventually 
a cicatriform depression in the skin (Lupus Exfoliativus, Lupus 
Psoriasiforme, " Lupus-psoriasis "). When a fibrous metamor- 
phosis occurs a sclerotic mass occupies the site of the former lupoid 
tissue, which in some cases progresses to extension of the lupoid 
patch in consequence of the further production of the toxin of the 
bacilli in the site affected ; and in others produces cicatriform tissue 
resembling that left after involution without ulceration of the gumma 
of syphilis (Lupus Scleroses, Sclereux, Fibrosus). 

In the degenerating forms of lupus, ulceration may begin by break- 
ing down the epidermis over the lupous tissue or by a more or 
less rapid transformation of patch or lesions into a cheesy semi-puru- 
lent mass of detritus. When pus is freely formed, whether super- 
ficially or deeply, crusting ensues, the debris of epidermis being entan- 
gled with the desiccated secretions. These crusts are variously colored, 
and differ in thickness with the severity of the degenerating process 
beneath. The oval or circular ulcers which furnish them are usually 
well defined, though irregular as to the margin, shallow, thin-edged, and 
flattish ; and their floors are dirty reddish or purplish, indolently gran- 
ulating, furrowed, hemorrhagic, or, when cicatrization is in progress, 
healthy. The destruction produced by involution of a lupous patch may 
be both by resorption and ulceration in the same subject and at the same 
time. The two processes may also coincide with an outbreak of fresh 
lupous tubercles, which later may develop at one point or another of 
the patch undergoing involution, probably from emigration of bacilli 
at the point of advance. In other cases lupus may spread by the 
formation of fresh nodules and plaques separated by islets of sound 
skin from those previously degenerated. When the ulceration advances 
it may be superficial, deep, or have other peculiarities, and be subject 
to other accidents of the ordinary process of ulceration, whence the 
names Lupus Serpigixosus, Profuxdus, Superficialis, Gax- 
grjexosus, Exulceraxs, Eodexs, etc. Lupus Crustosus and 
Rupoides are terms descriptive merely of the incrustations which 
form in some cases. Exuberant granulations elevating the floor of the 
ulcer may produce the condition termed Lupus Fuxgosus, Lupus 
Fuxgoides, Lupus Yegetaxs. Lupus Keloides indicates a cica- 
tricial overgrowth of the scar-tissue left after any one of the several 
conditions described above. 

One of the most conspicuous features of lupus vulgaris is its essen- 
tially chronic course. It requires far more time for its complete evolu- 
tion than either syphilis or carcinoma ; and in this point is best 
compared with lepra. For a quarter of a century a lupus-patch may 
be limited to a space no larger than the palm of the hand, and exhibit 
some evidence of activity during the greater part of that period. 



656 NEW-GROWTHS. 

Lupus of the Face. — Here the first manifestation is the so-called 
primary efflorescence, exhibited on one or both cheeks, nose, or cheek 
and nose, as a dull-colored maeulation or minute nodule, often long 
unnoticed, or as a finger-nail-sized, purplish thickening of the skin. 
Extension may then occur by multiplication of the lesions, or by 
spreading of the single patch, the central parts wasting or cicatrizing. 
The contracture of the irregular scars thus resulting may produce an 
ectropion of the lid or lip, and with this is often seen the " bouffissure " 
of the features already described. Crusting and ulceration may be 
conspicuous or well-nigh absent features. Gradually the subcutaneous 
tissues become involved. 

The nose, after absorption of the lupous tissue, may become shrunken 
and retracted to a miniature of its former dimensions, its tip being 
noticeably reduced to a sharp point, producing thus a characteristic 
deformity suggesting the beak of a parrot. In other cases the point 
becomes bulbous, flattened, livid, and knobbed, with a thickened sep- 
tum and distorted alse, an isolated patch or two of lupous infiltration 
showing in the neighborhood of the cheek on one or both sides. The 
last described condition may lead by degenerative processes to the first, 
but is more commonly noticed as a less severe and more localized 
involvement of the face, which may terminate, in favorable cases, 
without the severe mutilation first described. 

The subcutaneous tissue, mucous membrane, cartilages, and bones 
may be destroyed ; and in place of the nasal organ itself there may be 
left eventually two ovoid cavities in the face, separated merely by the 
posterior flange of the septum. 

Often large portions of the skin of the head (cheeks, lips, nose, eyelids, 
chin, ears, brow, and neck) become altered by the lupous growth. The 
resulting thickening produces a marked and characteristic deformity, 
reducing the openings of the mouth and lids to narrow slits, interfering 
with vision, speech, and mastication, and producing a marasmus from 
these causes alone, before there is ulceration at any point. 

The ravages of the disease are at times frightful in severity ; not 
merely in consequence of the destructive ulceration to which it tends, 
but from the deformity left by awkward attempts at repair. The en- 
tire surface of the head may be thus converted into a hideous travesty 
of humanity, while yet its possessor is left with all vital organs and 
functions apparently unimpaired. 

The upper lip, when involved, becomes first swollen, fissured, hem- 
orrhagic, and crusted : and a granulating surface indicates extension of 
the disease to the adjacent mucous surface. Later, if the ulcer heal, 
the mouth, by contracture, is reduced to a repulsive-looking slit or 
chasm in the face, permanently retracted, and either open or closed. 
The gums, lining membrane of the lips, velum, and hard palate may 
also be granulating, eroded, or whitish, when the exfoliated epithelium 
is in situ. Ulceration and cicatrization here also produce deformities 
interfering with the function of the parts, aphonia, for example, result- 
ing from the operation of these causes in the larynx. 

Lupus of the Ears may be symmetrical in development, or affect 
but one auricle. As in eczema, a favorite point of election is the lobule, 



TUBERCULOSIS CUTIS. 657 

which, with or without tumefaction of the whole organ, becomes a 
pyriform, purplish, dependent tumor, agglutinated speedily to the 
cheek. Later, when ulceration occurs, the auricle may disappear or 
be reduced to a shrunken shell of its former state, the external audi- 
tory meatus being, by the same process, occluded. 

Lupus of the Trunk is, as a rule, more extensive and less de- 
structive than lupus of other parts. Giant areas over the loins, hips, 
and belly may be involved in superficial, serpiginous ulceration, the 
centre healing as the peripheral ring spreads. In these cases it is even 
more difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes, and 
then, as a rule, has extended thither from affected areas of the adjacent 
integument. It is one of the rarest of the locations involved. 

Lupus of the Extremities is remarkable for its interference with 
the mobility of the smaller bones of the hands and feet, as a result of 
rigid cicatrices, and also for the production of caries and osseous ne- 
crosis. Mutilating effects are thus produced by loss of phalanges, and 
also by shortening of the hand or foot after the destruction of bone. 
Elephantiasic enlargement of such organs as the hands and feet thus 
corresponds to the livid tumefaction seen occasionally in the face. 
Thickenings, ridges, knobs, nodules, warty excrescences, ulcers, crusts, 
and callosities are often commingled, and in patients of mature years 
strongly resemble some forms of vegetating and ulcerating epi- 
thelioma. 

Lupus of the Mucous Membranes may or may not mean exten- 
sion of the disease from an affected adjacent integument. The lupous 
nodule, in consequence of warmth and moisture, is here transformed 
into a moist papillary outgrowth, or externally granulating patch which 
may ulcerate and cicatrize. The borders of such an affected area are 
well defined, and its surface is reddish and florid, quite pallid, white 
and glistening, or of a dirty grayish-white color where the investing 
epithelium is loosened but not yet detached. 

The soft is more often involved than the hard palate, but these 
parts w T ith the tongue, larynx (epiglottis, interarytenoid fold), and 
gums may be extensively invaded. Often for from two to five years 
the disorder may make no apparent advance, being limited to patches 
of red, swollen, coarsely granulating, whitish or glistening mucous 
membrane, with ulcerating and cicatricial processes slowly resulting. 
The lymphatic glands beneath the jaw and in the subclavian region 
may be simultaneously enlarged. In connection with the characteristic 
lupoid nodules grayish growths of the character of small tumors may be 
recognized in the larynx, with the result of partial occlusion of the rima 
glottidis. Patients may suffer from apical pulmonary tuberculosis, pre- 
sumed to be the result of extension of the disease from laryngeal lupus. 

" Lupus Demisclereux de la Langue." — Leloir l pictures and 
describes the features in the case of a girl fifteen years of age, with 
lymphatic adenopathy, typical lupoid nodules about the nose, and char- 
acteristic " parrot's beak deformity " of the latter. The middle of the 
dorsal surface of the tongue displayed smooth, pea-sized and larger 

1 Internat. Atlas, 1889. 
42 



658 NEW-GROWTHS. 

sclerotic nodules, grayish yellow, firm and softish, separated by fur- 
rows, and non-ulcerative. The palate, uvula, and larynx were involved. 
Tubercle-bacilli were recognized and cultivated in series, and inocula- 
tion of the cultures produced tuberculosis in guinea-pigs and a rabbit. 
Esthiomene (so-called " Lupus of the External Genital Organs of 
Women "). — In the year 1849 Huguier published a report of cases 
under the title of esthiomene, which have been the basis of a concep- 
tion widely prevalent since that date, that lupus of the vulva presents 
certain peculiarities not displayed by the same disease elsewhere. The 
subject has been restudied with special care by several observers, in- 
cluding one of us, and by Taylor, of New York. Lupus is among the 
exceedingly rare affections of the external genitalia of women, and 
where existing does not in any special way differ from its manifesta- 
tions in other regions of the body. The "esthiomene" of Huguier 
and his followers is a complexus of differing disorders, including cases 
of syphilitic sclerosis, secondary lesions, and gummata ; and hyper- 
trophies of the genital organs due to chronic " chancroid," traumatisms, 
and inflammations of a simple character aggravated by filth. It is not 
known to be a tuberculosis of the vulva, though it is possible that 
some tuberculoses may have been included in the category. 

2. Tuberculosis Cutis Verrucosa. 

There are several forms of tuberculosis of the skin in which lesions, 
differing both in appearance and career from those described in con- 
nection with lupus vulgaris, have been demonstrated to be the result 
of the encroachment of bacilli of tuberculosis upon the integument. 
The lesions exhibit for the most part a verrucous or warty appearance, 
and are illustrated well in the most distinctive clinical member of the 
group, the anatomical tubercle. In 1884 bacilli were discovered first 
in its mass, and in the year 1886 Biehl and Paltauf pointed out the 
connection of this lesion with cutaneous tuberculosis. 

(A) Verruca Necrogenica (Post-mortem Tubercle, Dissection- 
tubercle, Anatomical Tubercle). — Verruca necrogenica is a vesic- 
ulo-pustular or wart-like symptom of cutaneous tuberculosis, situated 
usually on the hands, and resulting, for the most part, from contact 
with bodies of the dead. 

This lesion was named first verruca necrogenica by Wilks. 1 It 
occurs on the fingers (especially on the dorsum of the thumb and of 
the index) of those engaged in the habitual handling or dissection of 
cadavers, and results from such professional contacts, from dissection- 
wounds, aud from all accidental inoculations with tuberculous virus. 
Cases are reported in which the lesion has had a non-cadaveric origin. 
It begins at the site of an abrasion or wound as a vesico-pustule, 
with deep-seated base and reddish or reddish-purple areola. This is 
productive of a burning, smarting, or pruritic sensation. The lesion 
accomplishes a period of bursting and crusting, which may be followed 
by complete involution. Several isolated or grouped papules, nodules, 
or tubercles may be formed, one or a patch of several being subse- 
quently covered with villosities or undergoing atrophic changes over 
1 Guy's Hospital Reports, s. 3, viii., p. 263. 



TUBERCULOSIS CUTIS. 



659 



an area several inches in diameter. Dermatitis and suppuration, very 
rarely ulceration, may complicate the process, though at times the first 
symptom of infection is an ulcer forming at the site of a cicatrix. 
The typical so-called "anatomical tubercle" is indurated and horny. 
A pigmented verrucous papule or tubercle very slowly forms, which 
may become fissured at one or more points. The characteristic lesion 




Tuberculosis verrucosa cutis. 

is the thickened, indolent, more or less pigmented and fissured, split- 
pea to bean-sized wart, usually single, found on the finger of the anato- 
mist. This may persist as an apparently innocuous lesion for months 
or years, or suddenly assume a formidable aspect. 

In other cases grave symptoms result, either in the involvement of 
the deeper tissues (subcutaneous, thecal, tendinous, periosteal), or in the 
production of erysipelas, pyaemia, septicaemia, or gangrene. Surgeons 
divide these cases into mild and acute varieties, according to the symp- 
toms exhibited. The records of the medical profession in almost every 
one of the large cities of every country contain the names of one or more 
eminent men whose lives have been sacrificed in this manner. In a 
few instances the local process has been followed by generalized tuber- 
culosis. 

(B) Tuberculosis Verrucosa Cutis (Riehl and Paltauf ) (Lupus Scle- 
rosus, Lupus Verrucosus, Scrofuloderma Verrucosum ; Fr., 
Lupus Papillaire Veruqueux ; Lupus Sclereux)— The lesions 
of this form of cutaneous tuberculosis occur often on the flexor aspect 
of the lower forearm, but also in other regions of the body, such as the 
integument covering the inner malleolus and the backs of the hands. 



660 NEW-GROWTHS. 

The plaques are insensitive, brownish red, movable, small-coin- to 
palm-sized, single or multiple, distinctly circumscribed, ovid or scal- 
loped in outline, and usually covered with minute pustules, fine 
pointed vegetations, and thin crusts. A characteristic violaceous halo 
commonly surrounds the whole. When healing occurs a smooth and 
scaling scar results. In those cases the papillary layer of the skin is 
chiefly involved. 

In the papillary layer of the corium the inflammation results in the 
production of numerous minute abscesses. Caseating nodules contain- 
ing tubercle-bacilli, giant-cells, and epithelioid cells are commingled 
with the abscesses. In some cases tubercle-bacilli are numerous ; in 
others their detection is difficult if not impossible, as in verruca 
necrogenica. 

The disease is to be most carefully distinguished from cutaneous 
blastomycosis, the lesions of which it closely resembles. Here a his- 
tological examination is essential. 

The disorder is said to be especially frequent of occurrence in those 
handling the dead or living bodies of animals. 

(C) Other Verrucous Tuberculoses. — An interesting series of morbid 
phenomena is presented when, for special reasons (proximity of tuber- 
culosis of organs other than the skin, accidents of position and ex- 
posure, influences that escape detection), sites of tuberculous infec- 
tion, whether primary or secondary in order, exhibit peculiar special 
symptoms : 

Tuberculosis Papillomatosa Cutis (Morrow's type) is by some 
authors assigned to verrucous tuberculosis (B). In these cases ex- 
uberant, soft, and florid excrescences rise to the height of one or two 
centimetres above the general level, closely packed together, with indi- 
vidual elements separated by deep fissures, the whole bathed in a puri- 
form mucus concreting in dark crusts. 

Fibromatosis Tuberculosa Cutis (Riehl). — In these cases there 
is not merely a papillomatous, but often a sclerotic growth found on 
the lips, nose, cheek, or about the anus or other mucous outlets of the 
body, interspersed with verrucous lesions, vegetations, and small shal- 
low ulcers. The tuberculous masses may be in the form of tumor-like 
bodies or thickenings of the subcutaneous tissue. 

Elephantiasis Tuberculosa Cutis is a term applied to gigantic 
overgrowths of the integument complicated by lymphatic occlusion. 
In these cases there has usually been a blocking up of the lymph- 
channels by an infarction produced by leucocytes charged with tubercle- 
bacilli. 

Tuberculosis Fungosa Cutis (Riehl).— In this class of cases 
tumors form resembling those occurring in mycosis fungo'ides, second- 
arily infected with tubercle-bacilli from other and usually adjacent 
organs (bone, muscle, etc.), the reddish-brown nodules first formed 
increasing to the size of a hen's egg. These may surmount large areas 
of infiltration and ulceration. Beside the tumors, minute pustules, 
vegetations, and crusts may be seen. Eventually typical tuberculous 
ulcers form. 

It is chiefly important to note in this connection that accidental 



TUBERCULOSIS CUTIS. 661 

inoculations with tuberculous material produce in different cases differ- 
ent clinical results, the essential part of the process being the transfer- 
rence of tubercle-bacilli. These infections are far more common than 
is generally understood. They occur in both the young and the old. 
Fox, of London, has reported such instances at the ages of seventy-two 
and eighty-two, respectively ; and Marmaduke Shield has seen cases of 
general tuberculosis of the aged, resulting from these accidents. 

3. Tuberculosis Cutis Orificialis. 

The clinical forms included under this title are those once supposed 
to be the sole manifestations of cutaneous tuberculosis. The title 
" tuberculosis of the skin " was, in fact, applied exclusively by many 
writers to the lesions observed by Kaposi, Jarisch, Chiari, 1 and others. 
These were indolent, oval or circular, shallow, discrete, reddish -yellow, 
granulating ulcers, often covered with thin crusts, occurring about the 
mucous orifices of patients affected with pulmonary tuberculosis (lips, 
anus, and vulva) and with development of miliary tubercles in the 
adjacent mucous tract. Tuberculous lesions of ulcerative type on the 
alse of the nose, over the lips, and about the ears, have been recognized 
in association with laryngeal, palatal, oral, pulmonary, and intestinal 
tuberculosis. 

In the case of a patient in advanced pulmonary tuberculosis, lately 
seen by us, there was a tuberculous ulcer near the anus, and also a 
well-defined patch of infiltration in near proximity, highly suggestive 
of some of the forms of lupus. 

Acute Tuberculosis of the Skin in children has been described 
under different titles (dermatitis tuberculosa acuta, tuberculose pseudo- 
ulcereuse) by Heller and Gaucher. In these cases macules, vesicles, 
bullae, papules, and pustules, terminating in deep, crusted, circinate 
ulcers, accompanied by caseation of neighboring glands, were found 
to contain bacilli ; and inoculations of cultures resulted in distinct 
tuberculous infection. These cases scarcely justify their separate classi- 
fication. They are properly placed with the clinical forms of disease 
termed, for provisional purposes, scrofulosis of the skin. 

EXANTHEMATIC MILIARY TUBERCULOSIS OF THE SKIN may follow 

the exanthematous fevers in children. The lesions are multiple, indo- 
lent, dull brownish-red tubercles, acuminate, situated in or near the 
cutaneous follicles and suggesting the lesions of acne papulosa. When 
in process of degeneration they form rounded, circular, or polygonal, 
sharply cut ulcers having a violaceous border, an irregular, granular 
floor, and a scanty sero-purulent discharge. Miliary nodules are to be 
seen both on the floor of the ulcerative surface and in the periphery 
of the lesion. They contain tubercle-bacilli. 

This disorder occurs, as a rule, in those exhibiting other and unmis- 
takable symptoms of tuberculosis. If the lesions be solely cutaneous, 
healing may result. 

1 Vierteljahr., 1879, vi., p. 269. 



662 NEW-GBOWTHS. 

4. Scrofuloderma. 

(Lat. scrofa, a sow.) 

The term Scrofula, or Struma, has been long and loosely applied in 
general medicine for the purpose of designating a number of diseases 
the real significance of which was unknown, their points of resemblance 
being greatly outnumbered by their specific differences. The researches 
of the last twenty years have been steadily and continuously restricting 
this list in almost every department of medicine. Many of the dis- 
orders once supposed to be scrofulous are now known to be syphilitic. 
In orthopaedic surgery a number of joint-affections once believed to be 
incontestably of strumous origin are known to be producible by 
traumatism exclusively. And in dermatology no less a broad advance 
has been made since the day when eczema, psoriasis, and acne were 
described as evidences of scrofula. 

The term scrofuloderma is applied now only to those forms of cuta- 
neous tuberculosis in which the skin is involved secondarily by direct 
extension of the process from tubercular glands, or other foci of tuber- 
culosis beneath the skin. By the term scrofula Billroth recognized a 
condition in which there occurs at any point in the body where irrita- 
tion has been induced an indolent inflammation, which persists after 
such irritation has ceased, which frequently terminates in suppuration 
and caseation, and which subsequently rarely pursues a hyperplastic 
career. If with this be conjoined inflammation and caseous infiltration 
of the lymphatic ganglia, or of the subcutaneous connective tissue, 
amyloid degeneration of one or several of the viscera, tumefaction of 
the belly, chronic keratitis, ophthalmia, otorrhcea, or coryza, a chronic 
arthritis (white swelling), a pasty, dirty colored, and thick or delicate 
and transparent skin, exhibiting cicatrices of old abscesses or ulcers, 
and a voluminous nose overlooking thick, everted lips, the general 
picture of the scrofulous patient may be considered complete. The 
recognition by Robert Koch of the etiological importance of the bacil- 
lus tuberculosis in tuberculous disease, and the demonstration of the 
presence of these micro-organisms in a number of lesions heretofore 
regarded as " scrofulous," have established their scientific position 
beyond controversy. 

The scrofulodermata are characterized by the occurrence of patho- 
logical processes in the skin, lymph-glands, or periglandular tissues, 
which betray evidence of the tuberculous process. They usually begin 
as firm, well-defined subcutaneous nodules, similar in type to the syph- 
ilitic gumma, which gradually enlarge, become attached to the skin, 
subsequently degenerate, exhibit characteristic ulcers, and usually ter- 
minate by no less characteristic cicatrices (" Gommes Scrofuleuses," 
"Gommes Scrofulo-tuberculeuses," " Scrofuloma," Cold Abscess of 
the Skin). 

The typical and commonest form of scrofuloderma is encountered 
about the face and neck, where the lymphatic glands have long been 
tumid, and are either dense or doughy to the touch. Usually this con- 
dition is reached very slowly ; often months and years are required for 
its production. The glands may be as small as almonds or as large as 



TUBERCULOSIS CUTIS. 663 

the closed fist. Gradually a characteristic dermatitis ensues in the 
skin which is superimposed. It becomes purplish and thinned, and 
finally yields, giving exit to a sero-purulent fluid mingled with caseous 
matter and blood. The pus-corpuscles of this fluid examined under 
the microscope are seen to be poor in protoplasm. Fistulous tracts and 
sinuses result, which undermine and perforate the skin, resulting in the 
production of a chronic discharge and characteristic ulcers. The latter 
are far more remarkable for their borders and bases than for their floors. 
They are usually linear, occasionally elongated and oval, almost never 
circular. As a result, their uneven floors, covered with pallid granu- 
lations and a watery pus, often are hidden beneath their inverted, 
tumid, and uncolored edges ; or the latter may be thinned, stretched 
over a fistulous pocket, and reddish or purplish in color. Their bases 
usually are attached deeply to the subcutaneous tissue, and are firm or 
soft, never densely indurated. The resulting crusts are thin, tena- 
cious, reddish or brownish, and, like the ulcer, often linear, rarely 
bulky, never rupioid. The resulting cicatrices are corded, depressed 
in irregular lines or bands, and often alternate, with equally irregular 
nodules (scrofulous gummata) where the degenerative process either 
has been arrested or is still in activity. 

Rarely, enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intramuscular tissue 
in the neck and even the extremities, in the course of which cartilage, 
bone, and periosteum are melted away. Usually but a few of these 
points of degeneration, from two to six, are exhibited in one patient. 

Another type of scrofulous gumma of the skin begins as a subcu- 
taneous nodule on the back or over the extremities of scrofulous children, 
the career of which is practically that outlined above. It differs chiefly 
from the lesion more or less directly connected with the lymphatic 
glands, by reason of its relation with lymphatic vessels distributed to 
a deeper and possibly distant tuberculous focus. 

According to Unna, there is a "dry" form which originates in the 
action of tuberculous toxin in the granuloma; and a "wet" form, the 
product of reaction of the nutrient channels and the resulting oedema. 
Tubercle-bacilli have been recognized in a few cases only, but their 
toxins have given rise to the pathological changes. 

Tuberculous Dactylitis, observed generally in children, is char- 
acterized by bulbous extremities of the fingers and toes, the skin cov- 
ering the same being at times the seat of infiltration and thickening. 
White l believes this process to be more common than that occurring 
in dactylitis syphilitica. 

Suppurative Tubercular Lymph angiectasis (Hallopeau and 
Goupil) is a condition in which scrofulo-tuberculous gummata, in 
small-nut- to egg-sized tumors, form along the lymph-vessels, of the 
lower extremity particularly. When such a tumor breaks down it 
furnishes the typical picture of the scrofulous ulcer, with its cheesy and 

1 Loc. cit. 



664 NEW-GROWTHS. 

watery pus, its thin edge, and its indolent career. In these rare cases 
bacilli have been recognized in the secretion. 

Tuberculosis Cutis Serpiginosa Ulcerativa is a term relating 
to a rare group of lesions in which brownish-red nodules, pea- to bean- 
sized, degenerate in the course of weeks or months until there results 
a centrifugally spreading, ovoid or roundish, even horseshoe-shaped 
ulcer, grayish yellow in hue and overspread with smaller cicatrices. 
Instead of nodules, the first lesions may be circumscribed areas of 
infiltration. The involved surface may be extensive, even larger than 
the two palms, and may coexist with secondary foci of involvement. 
Visceral and pulmonary tuberculosis may result. The resemblance of 
the large spreading patches to a serpiginous syphiloderm is striking. 

Lymphangitis Tuberculosa Cutanea (Besnier, Lejars). — The 
lymphatic vessels of the skin may be either primarily or secondarily 
invaded with tubercle-bacilli, and in either event linear lesions form 
corresponding to the lymphatic trunks, or there develop tuberculous 
nodules or warts, dermic or subcutaneous in situation, which event- 
ually ulcerate and discharge pus, blood, or lymph. At times a reticular 
network results, with fistulous sinuses. Several of the lymphangiectases 
have been demonstrated to be tuberculous in character. 

Etiology of Tuberculosis Cutis. — Accidental inoculation of tuber- 
culosis may occur at all ages and in all sexes, the infective material 
gaining access to the economy in the large number of instances by the 
medium of the lymphatics. There is, however, ampler opportunity for 
such transmission among the members of any family in which pulmo- 
nary tuberculosis exists ; hence the widespread belief in the heredity 
of the disease. Attention has, however, been already directed in these 
pages to the striking fact that children are rarely born into the world 
tuberculous ; and to the possibility that all cases of reputed inherited 
tuberculosis were acquired by direct infection. 

Given, however, an infective micro-organism, the soil upon which 
it may flourish most favorably is of paramount interest in an etiological 
view. The young, the delicate, the cachectic furnish such a culture- 
field. With these must be included, as favoring such accidents, the 
mode of life of the very poor, the filthy, and the degraded. Thus, 
lupus vulgaris is originally developed in the majority of all cases 
during the first decade, between the third and sixth years of life ; 
rarely after the thirtieth year, for the reasons above given. The sig- 
nificant fact in this connection is that at this period of life the child 
often deprived of the constant care of the mother by the demands 
made by a still younger infant, untaught in the simplest rules of clean- 
liness, picking and scratching the face after miscellaneous contacts of 
the fingers with all sorts of material, is exceedingly liable to inoculate 
the skin of the face with tuberculous virus, if there be victims of such 
disease occupying the same apartment or house. It is significantly first 
upon the face in these early years, and next over parts such as the 
extremities or the genital region, to which the exposed hands have been 



TUBERCULOSIS CUTIS. 665 

carried, that the early symptoms of lupus vulgaris are betrayed. 
Further, it is noteworthy that well-marked cases are more frequent 
among the poor, the filthy, and the degraded than among the comfort- 
able and cleanly. The prevalence of the disease in public as con- 
trasted with private practice is conspicuous in all statistics. 

As throwing additional light upon the question of childhood-infection, 
it is to be noted that other forms of tuberculosis occur at any period 
of life and in both sexes, when the accident of infection operates. 
Besnier, for example, reports a case of lupus resulting from tuberculous 
infection in vaccination ; Fournier, an instance in which a young woman 
was infected during the piercing of the ear for the insertion of earrings ; 
Jadassohn, a case in which the tuberculous virus was inserted by tattoo- 
ing; and Strauss, the history of a student who was wounded by a rapier 
in a duel, and as a result developed lupus in the site of the wound. 
In verruca necrogenica and warty growths of the same nature it is 
contact with the bodies of the dead or with tuberculous matter in any 
form that determines the result. The aged with tuberculous lesions 
upon the backs of the hands, middle-aged persons with other evidences 
of cutaneous affection, actually suffer from generalized tuberculosis as a 
result of the accident. All varieties are due to the local action of 
tubercle-bacilli. Tuberculosis verrucosa cutis results in the majority 
of cases from direct inoculation from external objects containing tubercle- 
bacilli. Lupus vulgaris also is produced in this way, but frequently 
the infection is brought to the skin through the lymphatics. In scrofu- 
loderma the bacilli find their way to the skin by direct extension from 
beneath, while tuberculosis cutis orificialis is an example of auto- 
inoculation, and is usually secondary to visceral tuberculosis. 

What may be said of the causes of lupus vulgaris relates also to 
scrofuloderma, which, while occurring in both sexes and at all ages, is 
more frequent in early life because of the susceptibility of the tissues 
at those periods. 

The soil fittest for scrofulodermatous manifestation is that where 
well-known agents have been most efficiently at work. All causes 
which tend to impair the nutrition and vigor of the body are, to an 
extent at least, efficient in its development, including privation from 
sunlight, fresh air, wholesome food, exercise, and hygienic influences in 
general. It is common among prisoners, exiles, and, in this country, 
among negroes and those of mixed blood. Consanguineous marriages 
are said to result often in strumous offspring. Syphilis in the third 
and fourth generations is known to be pathologically distinct from all 
the manifestations of scrofula. In many cases scrofuloderma is the 
sequence of other depressing medical diseases and surgical accidents. 
In certain instances, especially where it is limited to the neck, and 
accompanied merely by a cervical or submaxillary adenopathy, scrofu- 
losis is consistent with full vigor and nutrition of the body and all other 
evidences of sound health. 

Pathology of Tuberculosis Cutis. — Lupus vulgaris, tuberculosis 
cutis verrucosa, and scrofuloderma, as well as tuberculosis cutis orifici- 
alis (the one form hitherto recognized as tuberculous) are due to infection 



666 NEW-GROWTHS. 

with tubercle-bacilli, and are practically identical histologically with 
tuberculous lesions in other organs of the body. The discovery of 
bacilli in lupous tissue, first made by Koch, has since been verified by 
Doutrelepont, Weichselbaum, Meisels, Schuller, Lustig, and others. 
The striking resemblance first shown by Yirchow between a caseous 
miliary tubercle and a lupous nodule had, even before Koch's discovery, 
pointed to an identity of origin. The result of inoculation of culture- 
fluids has given positive results. Lenz, Huter, Schuller, ourselves, and 
others have produced tuberculosis by introducing in rabbits granula- 
tions taken from lupus and other varieties of cutaneous tuberculosis. 

For a knowledge of the microscopic characters of cutaneous tuber- 
culosis we are indebted largely to the Germans, whose opportunities 
for the study of the disease are unequalled. Virchow, Auspitz, Billroth, 
Lang, Kaposi, Klebs, Stilling, and Thin have contributed amply to the 
subject. 

The histological structure of the various forms of cutaneous tuber- 
culosis varies in minor particulars, but in essential features suffi- 
cient uniformity exists to enable the observer to discern that each is 
due to a similar exciting cause. Each is produced by the local action 
of the tubercle bacillus, and presents a cellular new-growth, vascular 
changes ranging from slight proliferation in the coats of the vessels to 
their complete obliteration, and attenuation, hypertrophy, or complete 
destruction of the collagen. The sebaceous and sweat-glands, hair- 
follicles, and elastin all suffer alteration, even to destruction. The 
epidermal changes in all are secondary, and include acanthosis, 
hyperkeratosis, parakeratosis, and scaling, and at times even complete 
destruction by ulceration. The tubercular nodule in the skin resembles 
that found in other organs, and consists, essentially, of one or more 
giant-cells immediately surrounded by a number of small, round cells, 
which have vesicular nuclei, and which are either mononuclear leuco- 
cytes or daughter plasma-cells (Unna). Interspersed among these may 
be a few multinuclear cells, and surrounding these is a zone of plasma- 
and connective-tissue cells. No vessels exist in the nodule, and the 
fibrous elements are either attenuated or completely absent. The 
nodule is surrounded in the nodular form of lupus by a collagenous 
capsule. In another variety no limiting capsule is present, and the 
cellular hyperplasia spreads along the lymph - spaces, producing an 
even, brownish discoloration of the skin, in which case giant-cells are 
not numerous. 

Degeneration occurs in the nodule, as is shown by the cellular pro- 
toplasm becoming homogeneous and the nuclei being incapable of 
absorbing stains normally. True cheesy degeneration seldom occurs 
in the skin, which fact might be accounted for by the relative scarcity 
of bacilli in most of these lesions. 

The cellular hyperplasia is composed of giant-cells, which are large 
oval, round, or irregularly shaped cells, containing as a rule many 
peripherally placed nuclei and having a homogeneous centre ; plasma- 
cells, which vary in size, are usually oval or oblong in shape, possess a 
large amount of protoplasm, and present an eccentrically placed vesicu- 
lar nucleus ; and small round cells, usually described as mononuclear 



TUBERCULOSIS CUTIS. 667 

leukocytes or daughter plasma-cells (Unna), which contain nuclei 
similar to the plasma-cell. In addition, some mast-cells are present, 
and in these the nucleus is surrounded by granules of protoplasm, 
which are identified by stains having metachromatic properties. Multi- 
nuclear cells are also present, and a large number of ordinary connec- 
tive-tissue cells. Tubercle-bacilli are found most abundantly in the 
acute miliary variety of cutaneous tuberculosis ; fewest in lupus vulgaris, 
in the lesions of which they are often difficult to demonstrate. Giant- 
cells are most abundant in lupus vulgaris, while cheesy degeneration, 
common to internal tuberculosis, is more prevalent in the miliary 
variety. Bacilli may be found between the cells, but are found more 
often in giant-cells. Animal inoculations may be performed success- 
fully in each variety, and they all react to tuberculin injections. 

Lupus Vulgabis occurs in two varieties, the nodular and the dif- 
fuse. In the former the tubercles above described are enclosed in a 
limiting capsule of collagen, w 7 hile in the diffuse variety the infiltration 
spreads evenly along the lymph-spaces without interruption, producing 
a diffuse infiltration. There is a tendency for the granuloma to be 
replaced by connective tissue, which at times proceeds to an excessive 
degree, producing a condition of elephantiasis. As the cellular infil- 
tration progresses the normal structures of the skin are atrophied or 
destroyed ; collagen, sebaceous and sweat-glands, hair-follicles, and, 
finally, elastin all disappear. Proliferative changes may occur in the 
epidermis, in which marked down-growth (acanthosis) of the rete into 
the corium results, producing the papillomatous variety of lupus, while 
with increased cornification verrucous forms occur. Pressure from 
below may rupture the epidermis, permit pyogenic infection, and result 
in ulceration. (Edema, with accompanying parakeratosis and scaling, 
may be present. All these epidermal changes are secondary, however, 
and are in themselves not tuberculous, the principal and characteristic 
changes being found in the corium. 

Tuberculosis Veeeucosus Cutis is distinguished by having the 
tuberculous plasmoma located chiefly in the papillary layer of the corium. 
The usual structure of the tuberculous nodule may be demonstrated. 
Marked acanthosis and hyperkeratosis are also distinguishing features. 
Miliary abscesses, produced by pus-cocci, may be found both in and 
beneath the epidermis. Tubercle-bacilli are usually more numerous 
than in lupus vulgaris and find their entrance from without. Both 
histologically and clinically this variety of tuberculosis is nearly iden- 
tical with some forms of lupus vulgaris, and now often is classified as a 
manifestation of lupus vulgaris. 

In Tubeeculosis Cutis Oeificialis, both in the number of bacilli 
present and in the type of lesion, there is an analogy with miliary tuber- 
cle of other organs. Large numbers of typical, circumscribed nodules 
are found deep in the corium ; bacilli are numerous and easily demon- 
strated ; the degenerative processes go on rapidly, the tubercles break- 
ing down and coalescing to form masses of softened necrotic tissue 
which soon break through the epidermis to form an ulcer. About 
the borders of such necrotic areas new nodules are constantly form- 
ing, and the whole process is rapid, as in acute tuberculosis of other 



668 NEW-GROWTHS. 

tissues. Histologically it is composed of the usual tuberculous plasmoma, 
its distinguishing features being the presence of large numbers of bacilli 
and also typical cheesy degeneration, which is not found in the other 
varieties. 

The Scrofulodermata originate in the subcutaneous tissues and 
involve the skin secondarily. The lymphatic glands or the tissues 
about the glands or lymphatic vessels become the seat of the tuber- 
culous process, which runs a subacute course. The glands or peri- 
glandular structures finally break down into softened necrotic masses. 
Such areas of necrosis may remain indolent and superficial, or, in 
case a gland is involved, may be deep and extend by burrowing 
prolongations even to the bone. Sooner or later the skin over these 
softened masses becomes involved in a subacute inflammatory process 
and gives way, producing the typical ulcer with soft, ragged, and 
often extensively undermined edges. Experimental inoculations and 
the presence of tubercle-bacilli have demonstrated these subcutaneous 
processes to be tuberculous. The number of bacilli present varies 
greatly, being much larger than in lupus, but much smaller than in the 
orificial forms of cutaneous tuberculosis. The relationship of the 
scrofulodermata to lupus is occasionally shown by the formation of 
typical lupous nodules near the border of these scrofulous ulcers, the 
result no doubt of inoculation of the skin with the discharge from the 
ulcer. The granuloma here consists of a diffuse plasma-cell infiltration 
with some giant-cells about the edges of the lesions. 

Diagnosis of Tuberculosis Cutis. — Epithelioma, though rarely 
resembling lupus vulgaris, is more often designated by that than by 
any other false title. Great confusion has arisen from the looseness 
with which several authors have furnished illustrations of " lupus 
exedens," which were really pictures of cancer. But the latter is 
rarely a disease of early life, and when of early occurrence may not 
persist to adult years ; the reverse of which is true in the majority of 
all cases of lupus. The nodules of lupus are absent in epithelioma, 
and the evolution of the disease slower, less painful, and, in its earlier 
periods certainly, of deeper situation. The ulcer of epithelioma is 
more often defined and single ; its edges whitish, indurated, and 
everted ; its floor uneven and glazed ; its secretion scanty and occasion- 
ally fetid ; its base a mass of indurated tissue. Lupous ulcers are often 
ill defined and multiple ; their edges soft and inconspicuous, neither 
everted nor undermined ; their floors granulating and flattened ; their 
secretion relatively profuse and generally odorless ; their bases soft arid 
pliable, though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis often re- 
semble certain forms of lupus. In any doubtful case a history of in- 
fection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in women, etc., should aid in the recognition 
of syphilis. The suspected lesions should be examined carefully for 
the purpose of distinguishing characteristic lupous nodules in the patch 
itself or in the periphery of any exfoliating area. In the case of an 
adult a history of long-existing lupus mav often be obtained ; and it is 



TUBERCULOSIS CUTIS. 669 

worthy of note that syphilis with exceeding rarity displays for long 
periods of time a single exanthematous lesion or aggregation of such 
lesions exclusively in one part of the body. Lupous ulcers, often 
multiple and isolated, insensitive, well- or ill-determined in outline 
(never reniform or horseshoe-shaped), with supple, low edges, and red- 
dish, smooth, hemorrhagic granulating floor, covered with crusts like 
soiled parchment of uniform thickness, do not resemble those of syph- 
ilis. The latter are often painful, single, circular, and clean cut in 
contour, with firm, raised, infiltrated margins, and with offensive green- 
ish and blackish crusts, resembling oyster-shells. The cicatrices of 
syphilis are elegant, smooth, delicate, superficial, circular, and, after 
pigmentation has disappeared, dead white in color; those of lupus 
are irregular, indurated, deforming, yellowish white and reddish yellow. 
Acquired syphilis is a disease of adult life ; lupus commonly begins in 
childhood. 

The disks of psoriasis are distinguished from flat exfoliating patches 
of lupus vulgaris by the relatively large number of the former, by the 
nacreous lustre of the scales, the reddish hemorrhagic surface beneath, 
and the sites of election of the disks, usually on the extensor faces of 
the limbs. 

Lupus erythematosus is even more readily distinguished by its char- 
acteristics ; including the absence of nodules, ulcers, and crusts, the 
superficial character of the morbid process, the scaliness, and occasional 
symmetry of the patches. An intermediate form between lupus ery- 
thematosus and lupus vulgaris has been described, but most cases so 
classed probably belong to the type called by Leloir " erythematoid 
lupus vulgaris," in which nodules are temporarily absent. In all such 
cases typical nodules of lupus vulgaris develop sooner or later and 
confirm the diagnosis. The two diseases, unfortunately somewhat 
similar in name, are distinct in character. The so-called intermediate 
forms may be instances of flat and scaly epitheliomatous infiltration 
going on to ulceration. 

In acne rosacea with a bulbous condition of the tip of the nose the 
redness is vivid ; and the telangiectasic complications, with the sebor- 
rheic flux, are conspicuous points of difference from lupus vulgaris. 
There is, further, no ulceration and little scarring, and the patients 
have usually suffered from the disease only after arriving at maturity. 
The mucous surfaces are also spared. 

The diagnosis of verrucous growths of tuberculous nature is to be 
made after an investigation of the history of each case, which often 
includes a record of contact with cadavers or persons capable of com- 
municating the disorder. The epitheliomatous warty growths on the 
dorsum of the hands of elderly persons are not to be confounded 
with tuberculous lesions. In the former there is commonly a history 
of longer existence of the wart, and no record of suspicious con- 
tacts ; while a careful search will usually determine epitheliomatous 
metamorphoses over the cheeks or temples of the elderly man or woman 
with epitheliomatous warts on the hands. In the latter, too, the 
facial lesions are usually multiple, fatty-looking scales, thicker in one 
part than another, resembling those of a severe seborrhea, but which 



670 NEW-GROWTHS. 

are removed with difficulty, and which then leave a bleeding surface 
beneath. 

In the orificial cases it must be remembered that tuberculosis of 
the viscera is a probable coincident disease. The microscope usually is 
needed for an exact diagnosis. 

Treatment of Tuberculosis Cutis.— The internal treatment of 
tuberculosis cutis is practically that indicated by the condition of 
the patient ; inasmuch as no medicament is known to be capable, after 
ingestion, of relieving the victim of his local ailments. Of the articles 
in this category none will be more often indicated than cod-liver oil, the 
chalybeates, creosote, the bitters, the preparations of iodine, and possibly 
phosphorus. Iodoform and potassium iodide have been recommended 
by Neisser, who employs the former in pills, each containing \ grain 
(0.033). Guaiacol and creosote carbonate, either of them, in 5 grain 
(0.33) capsules, have been used with varying degrees of success. In 
London thyroid-extract has been given for cases of extensive tuber- 
cular disease of the skin with seeming benefit, though no complete 
cures are reported. The hypophosphites are useful in many cases. 
Arsenic and mercury are powerless to prevent extension of the disease. 
It is needless to add that a diet of the most generous character is to be 
supplied, and the rules of hygiene enforced. 

Patients of the tuberculous class manifest in the highest degree the 
beneficial effects of a change of residence and climate — to the seashore 
or mountains from the interior valleys or plateau-lands ; often the 
reverse for those who reside by the sea or in mountainous countries. It 
is the change which seems to produce the greatest benefit. An abun- 
dance of pure air and a life permitting out-of-door exercise are of 
the highest importance. The thermal and other springs of several 
countries furnish resorts where the benefit received is proportioned to 
the salubrity of the climate rather than to the special advantages of the 
waters furnished. Unfortunately, a large number of the patients 
affected with lupus and scrofuloderma are impoverished inmates of 
public charities or applicants to dispensaries, where these aids in the 
management of their ailments cannot be utilized. 

The local treatment of lupus vulgaris should have in view the 
removal of the morbid growth as painlessly and with as little resulting 
disfigurement as possible. These ends may be attained by surgical 
measures and by chemical and other applications. 

The most satisfactory results in the treatment of lupus vulgaris are 
obtained with the Finsen light. Not only is the method successful in 
removing the disease in the large majority of the cases, but the scars 
produced are much less disfiguring than those left by other methods, 
except the results obtained sometimes by radiotherapy, or in some of 
the circumscribed areas treated by Lange's plastic method. 

Finsen and Forchhammer * have published recently the records of 

1 Mittheilungen aus Finsen's med. Lysinstitut, Nos. 5 and 6. German translation, 
Jena, 1904. The report contains 226 pages of text and the photographs of 48 patients 
before and after treatment. The tables are prepared with the greatest care and detail, 
the cases being subdivided into four grades of severity ; four grades according to extent 



TUBERCULOSIS CUTIS. 671 

the first 800 cases of lupus vulgaris treated in Finsen' s Lysiustitute in 
Copenhagen. These 800 cases were treated between November, 1895, 
and November 1, 1901. On October 1, 1902, the status of the cases 
was as follows : 

Excluding 71 cases in which death, illness, or other causes pre- 
vented a continuance of the treatment, there remained 729 cases in 
which the treatment was tested properly. Of these, 40, or 6 per cent, 
of the total number, received little or no benefit. The remaining 689 
patients, or 94 per cent, of the whole, were either entirely cured or much 
benefited by the treatment. Fifty-six per cent, were healed entirely, 
17 per cent, having been under observation for periods varying from 
two to six years, without recurrence of the disease. Eighty-two per 
cent, of the entire number were either entirely healed or showed but 
slight traces of the disease. These results are far better than those 
given by any other method of treatment, and are the more remarkable 
when the fact is considered that the Lysinstitute at Copenhagen attracted 
to it a large number of cases of from ten to fifty years' duration in 
which all other methods of treatment had failed. In common with all 
who have spent any time or done any work in the Institute, we can 
testify personally to the true scientific spirit manifested by Finsen and 
his associates, and consequently to the accuracy and trustworthiness of 
his reports, which established beyond question the value of the light 
treatment in this disease. The statistics demonstrate the frequency 
with which the mucous membranes are affected. In 72 per cent, of 
the cases the mucous membranes, usually of the nose, were involved 
more or less. Recurrences are due chiefly to reinfection of the skin 
from the mucous membranes, which in most situations are not amen- 
able to the treatment by light, but have to be controlled by other 
methods. Moreover, it is exceedingly difficult to determine when 
mucous membrane lesions have been eradicated completely. The fact 
cannot always be decided without prolonged observation. 

The reports on lupus vulgaris from the Finsen Institute alone are 
sufficiently convincing, but during the last few years many other ob- 
servers in Europe, among whom may be mentioned Sequeira, Morris, 
Leredde, Gastou, Stroebel, Lesser, and Schmidt, and a few in the United 
States, including ourselves, 1 have established the value of phototherapy 
not only in lupus vulgaris, but in other forms of cutaneous tuberculosis 
as well. 

The apparatus and general technique are described on pages 117— 
121. In lupus vulgaris, deep penetration of the light is desired; 
hence, sittings of an hour or more are necessary. An inflammation 
deeply situated in the skin follows and reaches its acme in from twenty- 
four to forty-eight hours. The entire surface then is covered with 
vesicles or with a single large bulla. As soon as the reaction has sub- 
sided, which usually follows in about ten days, the area is given another 

of surface involved ; and further according to the duration of the disease, age of the 
patient, and coincident involvement of raucous membranes. The numbers and dates of 
treatments, resulting reactions, periods of freedom from disease, dates of recurrences, 
and subsequent treatments, all are recorded accurately and definitely for each case. 
1 See report by one of us, Jour. Cutan. Dis., 1903, xxi., p. 529 (with bibliography). 



672 . NEW-GROWTHS. 

treatment, and the process repeated until lupous nodules no longer can 
be detected in the tissue. As it is impossible to decide just when the 
last trace of the disease has disappeared, patients should be instructed 
to return after a few months for subsequent examination. In extensive 
cases daily treatments may be required in order to keep all the surface 
involved constantly under the influence of the light. The number of 
treatments required for each area varies from one or two to six or 
more. 

Phototherapy is not so effective, however, and may fail entirely in 
cases in which the penetration of light is prevented by extensive pig- 
mentation, or in which perfect exsanguination of the tissue is impossible 
owing to the presence of thick or irregular scars, densely infiltrated or 
hypertrophic areas, or when the disease is so situated, as is usually the 
case in mucous membranes, as to be inaccessible to pressure and 
direct radiation. Crusts and other obstacles to the penetration of light 
should be removed by the usual methods. In some instances pyrogallol 
and other remedies may be used to lay bare the deeper nodules before 
applying the light. The expense of phototherapy for small areas is no 
greater than that of other methods, the results are achieved as rapidly, 
and the cosmetic effects are assured. In large areas on covered parts 
of the body and where the cosmetic effect is not important, the treat- 
ment may be reserved for such lesions as do not yield to more rapid 
and less expensive methods. 

The arrays have been used in cutaneous tuberculosis by Schiff and 
Freund, Kummel, Holland, Knox, Pusey and a number of other 
observers, including ourselves. The method is better than photo- 
therapy for the cases described above in which pigmentation or great 
thickening of tissue prevents penetration of light. The arrays are 
capable of removing not only the lupous nodules, but also of greatly 
reducing and improving the thickened and disfiguring scars so often 
seen in the disease following its spontaneous disappearance or its 
removal by other methods of treatment. It is possible with the #-rays 
to prodnce as perfect cosmetic results as are obtained regularly with 
the Finsen light ; but in some instances, and especially if during the 
course of treatment a severe dermatitis has been produced, the scars 
may be marked by distinct telangiectiasis and are not quite so perfect 
as those obtained in practically every instance by phototherapy. 
Moreover, to be effective, the arrays in cutaneous tuberculosis must be 
pushed to the point of producing a decided reaction which is more or 
less painful and may necessitate suspension of the treatment for weeks 
at a time. 

Radium has been employed in a few cases with results similar to 
those obtained by the arrays. 1 It apparently had no advantages over 
the two preceding methods, and its practical employment is prevented 
largely by the difficulty experienced in obtaining sufficient quantities 
of a definite radio-activity. 

The thorn treatment employed by Unna gives excellent results. 
The thorns of the gooseberry bush are saturated in the German " liquor 
stibii compositus," and one or more thrust firmly and deeply into each 
1 For references see p. 121. 



TUBERCULOSIS CUTIS. 673 

lupous nodule which it has been determined to attack. The base of 
each thorn is then cut off with a pair of fine scissors and the patch 
covered with a zinc oxide plaster. When the thorns are cast off a 
simple granulating ulcer is left which in favorable cases heals without 
delay. 

The obvious objection to each of the methods detailed above lies in 
the fact that an enormous proportion of lupus-patients have nasal and 
oral symptoms which canriot be reached either by the rays of solar or 
electric light or by Unna's thorns. The local treatment of these involved 
mucous membranes is a matter of great importance, and is described 
below. 

Hollander's hot-air treatment of lupus is accomplished by directing 
upon the lupoid tissue through a metal tube of slender diameter a 
stream of air at a temperature of about 300° C. The result is for the 
most part a destructive cauterization requiring complete anaesthesia. 
The resulting scars are formidable. 

The surgical procedure most frequently employed is curetting with 
a sharp spoon. This, with all other bloody operations in lupus vul- 
garis, labors under the disadvantage of the possibility that tubercle- 
bacilli may be disseminated by the traumatism. Competent authors 
are arrayed on both sides of this question. Small lupoid patches cer- 
tainly may be spread after resorting to most of the surgical devices 
employed as remedial agents. The dermal curette is a sharp-edged 
spoon with or without a fenestrum in the bowl to permit the escape 
of debris. By it the lupous growth may be completely scraped away, 
and, if necessary, caustics subsequently applied. Fox and others sub- 
stitute for the sharp spoon the dental burr or dental excavator, though 
the change is not always for the better. Morris's double parallel 
screw-excavator is an improvement on the common burr. Often it is 
well to supplement the action of the spoon or excavator with the flat 
electrode treatment of Jackson. Gartner and Lustgarten originally 
used as an electrode a flat silver plate attached to the negative pole of 
the battery, the plate being set in a hard-rubber ring. A current of 
from five to eight milliamperes is employed. 

The ablation of the entire lupous patch by the modern methods of 
surgery, followed by skin-grafting with the Thiersch or Lang method, 
gives good results, though the lupous growths may return sooner or 
later in the new skin. The objections to this method are chiefly that 
it involves the production of a larger and more conspicuous scar, since, 
as a rule, more tissue is removed by the knife than by the curette and 
its allies. In the Lang l method the excision is made to include both 
the sound peripheral integument and half of the subcutaneous fat- 
cushion beneath, the skin-grafts employed later differing from the thin 
Thiersch sheets in that they include the derma with the epidermis as 
far as the panniculus adiposus. 

The local treatment of lupus vulgaris by the aid of parasiticides is 
based upon the infectious character of the disease ; and in many cases 
is successful. White, 2 with a view to its parasitic action, applies to the 

1 Der Lupus und dessen operative Behandlung. Wien, 1898. 

2 Boston Med. and Surg. Jour., 1885, cxiii., p. 409. 

43 



674 NEW-GROWTHS. 

lupous patches rags soaked in solutions of mercuric chloride, 1 to 2 
grains to the ounce (0.066-0.133 to 30.), and also applies ointments 
containing the same quantity of bichloride in the ounce of salve-basis. 
Favorable results have been also secured by freely painting lupous 
ulcers with a solution of corrosive sublimate in tincture of benzoin of 
the strength named. Salicylic acid, 2 to 4 per cent, solutions in castor- 
oil, and in ointments J to 1 drachm to the ounce (2.-4. to 30.); sul- 
phurous acid, or pyrogallol in ointments of 10 per cent, to 50 per cent, 
strength, spread on linen rags, covered with impermeable tissue, and 
followed by the use of mercurial plaster and iodoform, have all been 
successfully employed with the same object in view. 

Decidedly inferior to these are the following methods, the first 
named, most popular in Germany; the second, in France; the third, 
to-day practically obsolete, and probably not to be revived : 

The Paquelin knife is extensively used in Vienna. The finer 
blades, especially manufactured for the purpose, are thrust, at a red 
heat, again and again through the lupous tissue until it is destroyed in 
its depth. Over the whole the larger blade is firmly passed and pressed, 
the blackish coal resulting being the best subsequent dressing after the 
serous exudation ceases. Erasion is also followed by the use of the 
galvano- or thermo-cautery. 

Multiple linear scarification, a modification of the Dubini-Volkmann 
method, was once claimed to have changed the prognosis of the disease. 
It is doubtful whether anything is to be gained by either a preliminary 
freezing of the part or the use of cutting instruments with many blades. 
The incisions may be produced with a delicate bistoury held in the 
fingers like a pen. They should be in parallel lines, closely set 
together, and crossed; should extend completely through the depth of 
the lupous growth ; and this is determinable after some practice by the 
cessation of the creaking resistance which the blade fails to discover in 
normal tissue. Further, these incisions should extend laterally beyond 
the borders of the lupous patch into the sound peripheral zone. The 
bleeding is trifling and readily arrested by firmly pressing small pieces 
of fine sponge, lint, or absorbent cotton over the part. The edges 
of the incision unite either by granulation or by first intention; and in 
both cases seem to serve as starting-points of the reparative process, 
the material for which, as already pointed out, seems to be supplied 
from the lupous nests themselves. Subsequent operations, when needed, 
require a previous freezing of the affected surface. In France and in 
some portions of the British Empire this method is still popular. 

Treatment by chemical cauterization alone is obsolete. The various 
acids and alkalies, particularly potassium hydroxide and lactic acid. 
Cosme's paste, silver nitrate, arsenical, mercurial, and zinc compounds, 
and sodium ethylate have all been employed thus, and in suitably 
selected cases have been in the past productive of fairly satisfactory 
results. 

With or without surgical interference, local applications may be 
employed, such as oily and fatty substances for the softening of crusts ; 
stimulating dressings of tar, iodated glycerin, thymol, guaiacol (Funk), 
ichthyol, carbolized glycerin, iodized phenol, fluorine (Phillipson), 



TUBERCULOSIS CUTIS. 675 

naphtol, chrysarobin, and iodoform ; as also the carbolated unguent- 
appropriate for the reparative phases of the ulcer left after the destruc- 
tion of the lupous growth. 

Unna advocates the topical application of 2 parts of beech-tar 
creosote to 1 part of salicylic acid, the latter for its marked effect 
upon lupous tissue, and the former for what is supposed to be its 
anodyne effect in obtunding the pain produced by the action of the 
acid on the surface. That this explanation of the effect of the com- 
bination is not wholly correct is shown by the well-known fact that 
creosote alone is capable of producing a curative effect upon lupous 
tissue. In a former edition of this work, issued before the date of 
Unna's experiments, creosote was set down as the dernier ressort of the 
physician in the topical management of lupus vulgaris. It can be 
used with the greatest advantage in severe cases not only by being 
brushed freely over the part, but also in the combinations suggested by 
Unna. It will be found that when employed alone it is far from hav- 
ing at first the local effect of a " morphine of the skin," being produc- 
tive, where no cocaine has been previously employed, of exquisite pain, 
which, however, is usually short lived. It should be applied only with 
the greatest caution by the practitioner's own hands, its effects watched 
and, if need be, counteracted, as in the local employment of potassium 
hydroxide. Trikresol operates in a similar manner. 

The application of fuchsin in 1 or 2 per cent, alcoholic solutions 
painted over the part, which has been previously scarified, is advocated 
by Fox and others. We have employed pyoktanin-blue in some cases 
with satisfactory results. 

In some of the German hospitals the new tuberculin-R, Koch's 
lymph, is injected, and, it is claimed, with a larger success than follows 
the older methods. It has not been unattended with danger, and fatal 
results have in a few instances been recorded after its injection. In 
other cases general tuberculosis has been induced ; while in yet others 
the degree of improvement following its employment has been inferior 
to that more readily reached by other therapeutic measures. The dose 
is 5^-q to 1 milligramme, the strength being very gradually increased 
from the smaller to the largest amount named. 

The injection of calomel into the lupous patch has been followed by 
good results in the hands of Da Costa, Brouse, and Tschlenow. 

The treatment of verruca necrogenica and other verrucous tubercu- 
loses of the skin is practically that of lupus vulgaris. The curette 
may be followed by one of the caustics advocated above, preferably by 
pyrogallol, or a combination of salicylic acid and creosote. As a rule, 
mercurial lotions and salves are not well adapted to penetration of the 
warty or corneous envelope of the growth. 

The orificial lesions of tuberculosis cutis may, however, be well 
treated by these lotions, especially one in which \ to 2 per cent, of 
mercuric chloride is dissolved in compound tincture of benzoin or tolu. 

Veiel applies in all the cutaneous tuberculoses pyrogallol-vaselin in 
the strength of 10 per cent., spread upon lint for three or four days. 
One part to twenty of salicylic acid may often be advantageously 
added. 



676 NEW-GROWTHS. 

The local lesions of scrofuloderma may require the use of hot borated 
lotions applied temporarily, or kept permanently in contact on com- 
presses covered by impermeable tissue. The results of surgical abla- 
tion of enlarged lymphatic glands, broken down or threatening scrofu- 
lous "gummata," and the complete disinfection and aseptic treatment 
to the point of cicatrization of the resulting wounds, furnish proofs of 
the progress of modern surgery. 

The Prognosis of tuberculosis of the skin in all its manifestations 
is in the highest degree variable. Many patients affected with lupus 
vulgaris, even after the production of the severest grade of deformity, 
recover and without further local manifestations gain a degree of facial 
comeliness that is marvellous. The scrofulodermata in the same way 
are remarkably improved, in the majority of all cases, by skilful medical 
and surgical management. In other cases systemic tuberculosis develops 
after even a single tuberculous infection, and grave results may occur 
either early in life or after years of tuberculous involvement of the skin 
and other organs. Other things equal, the prognosis in tuberculosis 
of the skin, as compared with that of other organs, is relatively favor- 
able, due to the sparsity of tubercle-bacilli in most cutaneous lesions, 
the skin being exposed too largely to external influences to form a 
good field for development of new colonies of bacilli. Any form of 
tuberculosis of the skin, however, may result in systemic infection 
and death. 

DERMATOSES PROBABLY TUBERCULAR. 

Lichen Scrofulosorum. 

(Lichen Scrofulosus.) 

This eruption, first described by Hebra, 1 is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, belly, and 
thighs, of millet-seed- to pinhead-sized, firm, flat, light- to livid-red, 
and grouped papules. These are occasionally surmounted at the apex 
by a minute scale, rarely by an equally small pustule. The lesions are 
at the onset isolated ; later they tend to arrange themselves in coin- 
sized patches ; when evolution is accomplished they are closely set 
together, the surface of the skin being then of a dirty reddish-brown 
color, and covered with thin scales, which are readily detached. Often 
a crescentic outline can be determined in a group of aggregated 
lesions. 

The course of the eruption is slow ; often the cutaneous symptoms 
persist for months without apparent change, awakening little or no 
pruritus, and are followed by involution, accompanied by slight des- 
quamation and no cicatrices. There may be recurrence. 

Etiology and Pathology. — In 99 per cent, of all cases observed 
in Austria there was concomitance of the general symptoms of struma 
named above (submaxillary, cervical, and axillary adenopathy, peri- 
1 See his remarks before the German Surgical Society, XIV. Congress. 



DERMATOSIS PROBABLY TUBERCULAR. 677 

ostitis, ulcerative dermatitis, etc.), with frequent complications, such as 
eczema of the scrotum. The disease was encountered in young tuber- 
culous subjects between the periods of infancy and puberty, rarely after 
the twentieth year. Crocker 1 has noted its frequent occurrence in 
children in whom he suspected tubercular pleurisy. Jadassohn 2 be- 
lieves that it is a disease of the tuberculous, and not of the cachectic 
generally, and obtained typical reactions in fourteen of sixteen cases 
injected with tuberculin. He has seen the disease disappear after these 
injections. As to the question of its toxic or bacillary origin, opinion 
is still divided. In favor of the former theory, Schweninger and Buzzi, 3 
Porges, 4 and others have seen a disease apparently identical with it 
produced by tuberculin injections. It has been suggested that the 
injections may have stimulated a latent tuberculosis into activity, but 
in the histological study of a case thus produced Porges 5 found merely 
changes of an inflammatory character, with no evidence of a tubercular 
structure. In a case of lichen scrofulosorum in a negro child, Gilchrist 6 
found a granuloma deeply situated, while the folliculitis which produced 
the clinical symptoms was more superficial. 

According to Kaposi, the disease consists in an exudative infiltra- 
tion of the pilo-sebaceous follicles and the perifollicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infiltrated 
perifollicular annex ; and its apical scale or pustule is formed of a mass 
of epithelial debris or an inflammatory exudate. Porges found areas 
of tubercular foci composed of round, epithelioid and giant-cells in the 
corium. The vessels showed perivascular inflammation, with cellular 
infiltration about the sweat-ducts. Jacobi, 7 WolfF, 8 and Pellizarri 9 have 
been successful in finding the bacillus in the lesions or in producing 
inoculation tuberculosis in guinea-pigs. 

Diagnosis. — The disease is differentiated readily from papular eczema 
by the absence of itching. From the miliary papular syphiloderm it 
differs in that the lesions of the latter, even though grouped, are always 
individually distinct. The general symptoms, moreover, are strikingly 
different in the two diseases. Lichen scrofulosorum should not be con- 
founded with lichen planus or lichen ruber, Lichen pilaris, however, 
in a young and lymphatic patient might readily be mistaken for the 
disease in question. 

Prognosis and Treatment. — The prognosis is good. If left alone, 
the malady produces but little inconvenience, and, moreover, yields 
readily to treatment. Hebra advised cod-liver oil internally and ex- 
ternally. Crocker advises liquor plumbi subacetat. grains 15 (1.), 
thymol grains 5 (0.33), to vaseline 1 ounce (30.), to be applied exter- 
nally, with the administration of cod-liver oil internally. 

1 Diseases of the Skin, p. 448. 

2 Trans. Internat. Cong. Derm, and Syph., London, 1896, p. 425. 

3 Quoted bv Brocq, Twentieth Century Medicine, vol. iv., p. 359. 

4 Archiv, 1903, lxvi., p. 401. 

5 Fox, Brit. Jour. Derm., 1900, xx., p. 384. 

6 Johns Hopkins Hosp. Bull., 1899, x., p. 84. 

7 Verhandl. der Deutsch. derm. Gesell., III. Cong., 1891, p. 69. 

8 Ibid., VI. Cong., 1899, p. 

9 Pellizarri, Trans. Internat. Cong. Derm, and Syph., London, 1896, p. 425. 



678 NEW-GROWTHS. 

Erythema Induratum. 
(Erytheme Indur£ des Scrofuleux, Bazin.) 

Erythema induratum is a chronic recurring disorder, usually involv- 
ing the skin of the legs of young individuals, characterized by deeply 
situated nodosities and ulcerations. 

Symptoms. — The beginning of the disorder is marked by one or 
several deep-seated nodosities located in the hypoderm, which gradually 
extend to the surface and undergo necrosis, producing ulceration, or after 
absorption atrophy. They occur in successive crops, and may continue 
for years. They are usually bluish-red in color, though they may be a 
vivid red. They are painless as a rule, though pain may ensue after 
ulceration has occurred. The disease commonly attacks the calves of the 
legs of girls from fourteen to twenty years of age. Crocker has seen it 
in a woman of over fifty, but she had suffered with the disease earlier in 
life. It also has been observed in boys and men, but not commonly. 
The front of the leg may be involved occasionally, and also the thigh and 
even the upper extremities (Crocker and Galloway). The nodules are 
hard, and can often be felt by palpation when not visible. They vary 
in diameter from one-half to one inch or more. Node-like patches may 
also be present. The lesions are symmetrical and may be few; but in 
time a number develop. The ulcers are irregular, ill-conditioned, with 
puriform contents, and tend to heal slowly, leaving scars. At a given 
time there may be present nodules, ulcers, atrophic areas, and scars, 
some of these being relics of former attacks. The disease occurs, as a 
rule, in public practice and is comparatively rare. It has been observed 
in connection with tuberculides of the folliclis type, and also in patients 
having tuberculosis elsewhere than in the skin. 1 

It is probable that, in the past, two diseases have been described 
under this heading : first, as described above, which is the type and is 
probably tuberculous ; the other an ulcerative process due to vascular 
disturbances (Galloway, 2 Whitfield 3 ), this latter often occurring at a more 
advanced age, being more painful and more amenable to treatment. 

Etiology. — The affection occurs most frequently in the winter, and 
much more commonly in the female sex in the second decade of life. 
Washerwomen and shop-girls who stand much are liable to it. Its 
subjects often have a weak peripheral circulation, evidenced by cold, 
blue hands or a chilblain tendency. The tubercle-bacillus, in the light 
of recent study, plays an important role in the type cases. 

Pathology. — From the studies of Fox, 4 Thibierge, 5 Mantegazza, 6 
and others, the tuberculous nature of the disease seems well demon- 
strated, although inoculation experiments are usually negative and 
the presence of Bacillus tuberculosis difficult to demonstrate. A 

1 Crocker, Diseases of the Skin, p. 812. 

2 Brit. Jour. Derm., 1899, xi., p. 206, and 1902, xiv., p. 199. 
3 Ibid., 1901, xiii.,p. 386. 

4 Ibid., 1900, xii., p. 383 (Eeport on the Tuberculides, presented to the Fourth Inter- 
national Congress of Dermatology and Syphilis). 
6 Annales, 1899, s. 3, x., p. 513. 
6 Ibid., 1901, s. 4, ii., p. 498 (abstr. in Brit. Jour. Derm., 1901, xiii., p. 438). 



DERMATOSES ASSOCIATED WITH TUBERCULOSIS. 679 

granuloma with giant- and plasma-cells common to tuberculosis has 
been demonstrated repeatedly. Successful inoculations into guinea-pigs 
have been made by Fox and Eyre, Thibierge, and Ravant, and evidence 
is constantly accumulating which adds strength to the theory of its 
being produced by Bacillus tuberculosis. 

Diagnosis. — Erythema nodosum and syphilis are the two diseases 
most likely to cause confusion in diagnosis. From the former, erythema 
induratum is distinguished by its chronic course, its tendency to ulcera- 
tion, the absence as a rule of pain, lack of fever, and other constitutional 
symptoms, the presence of scars, and its frequent association with other 
evidences of tuberculosis. From the gummatous syphiloderm it is 
differentiated by the symmetry of the lesions, and absence of other evi- 
dences of syphilis ; finally, it is not benefited by specific treatment. 

Treatment. — General tonic treatment indicated in tuberculosis 
should be # used in most cases. Rest in bed with elevation of the limbs 
is recommended. Before ulceration, bandaging should be practised, 
and local antiseptic dressings after this last has occurred. 

DERMATOSES ASSOCIATED WITH TUBERCULOSIS. 

(Tuberculides [Darier], Toxituberculides [Hallopeau], Para- 
tuberculoses [Johnston].) 

Under the title Tuberculides Darier l classed a number of cutaneous 
affections which appeared to have many characteristics in common. 
These diseases, or, rather, cutaneous manifestations of disease, have as a 
rule been observed in individuals the subjects of tuberculosis in other 
organs than the skin, or who have hereditary tuberculous tendencies. 
Hallopeau and others have suggested that they are due not to the 
local action of Bacillus tuberculosis, but to the toxins floating in the 
circulation from a distant focus. Fox 2 says that if they are due to 
the local action of Koch's bacilli, they must be few in number, of 
little virulence, and readily destroyed. Darier included in this category 
acne cachecticorum or scrofulosorum, disseminated or agglomerated 
folliculitis, acnitis, folliclis, hydrosadenitis destruens or suppurativa, 
granuloma innominatum, disseminated erythematous lupus (Boeck), 
etc. Fox, in his report on the tuberculides to the International 
Congress in Paris, in 1900, included among others in this list acne 
varioliformis, necrotizing chilblains, lichen scrofulosorum, and erythema 
induratum scrofulosorum (Bazin). The two disorders last named 
are here considered by themselves, placing them between the accepted 
tuberculous diseases and the class of tuberculides. Evidence is 
accumulating rapidly which tends to confirm the position of these 
two in the tuberculous column. According to Fox, "the essential 
lesion of the group of tuberculides is a small, extremely indolent 
granuloma, tending to undergo central softening and necrosis, and 
thus leaving scars. They are bilateral and symmetrical. The great 
clinical variety depends upon the depth at which the derma is affected, 

1 Annales, 1896, s. 3, vii., p. 1431 (tuberculides). 

2 Brit. Jour. Derm., 1900, xii.,-p. 383 (Keport on the Tuberculides, presented to the 
Fourth International Congress of Dermatology and Syphilis). 



680 



NEW-GROWTHS, 



the implication or freedom of the glandular apparatus, the bulk of 
the granuloma, the distribution and number of the lesions, and the 
absence or presence of pustulation or necrosis." The subjects of these 
disorders often have a feeble peripheral circulation and are usually not 
robust. Two or more of these various lesions have frequently been 
noted in the same patient : for instance, lesions of the folliclis type on 
the upper extremities, with erythema induratum on the lower, or acnei- 
form lesions with lichen scrofulosorum. A patient whose case was 
reported by Johnston l had lesions on the arms which Johnston termed 
"necrotic granuloma," and others on the limbs which he termed 
" indurated erythema." Darier reported a case in which tuberculosis 
was present in the lungs and elsewhere, with tuberculides of the type 
of acne cachecticorum on the body, folliclis on the knees and extremi- 
ties, and a tuberculous gumma on the leg. Little 2 showed a case at 



Fig. 72. 




Generalized tuberculide ; small papular and verrucous lesions. 

the London Dermatological Society with acneiform lesions and gum- 
matous tuberculous lesions present at the same time. Fox notes that 
large gumma-like lesions often are associated with acneiform symptoms 
elsewhere. 

Symptoms, — These vary, as described above, according to the type 
of lesions present. In general, the disorders are chronic, the lesions 
deep-seated, beginning usually in the hypoderm or corium, extending 
into and involving the surface ; they are at first colorless, later bluish- 
or brownish-red or lighter in shade. They may suppurate, forming a 
pustule in the centre of the lesion. The latter dries into a depressed 
crust, which, when shed, leaves a small cicatrix; or ulceration may 

1 Phila. Med. Jour., 1899, iii., p. 443. 

2 Brit. Jour. Derm., 1902, xiv., p. 352. 



DERMATOSES ASSOCIATED WITH TUBERCULOSIS. 681 

occur, leaving a small depressed scar ; or the lesion, nodule or papule, 
may be absorbed, leaving some atrophy with pigmentation. The 
lesions often are grouped and appear in successive series. Different 
types show a predilection for different parts of the cutaneous surface. 
For example, lesions of the acnitis type select the face ; those of the 
folliclis type as a rule select the extremities. The lesions are gen- 
erally painless and do not itch, and there may be a large number or 
only a few exhibited. 

Acnitis Type. — This variety Crocker 1 describes under the title 
" Acne Agminata." Here the lesions select chiefly the face. They 
occur in distinct groups in different regions, especially upon the cheeks 
below the eyes, the upper lip, the chin, and the forehead. The lesions 
are usually brownish-red in color, though many appear semitranslucent 
and almost colorless. They vary in size from that of a pinhead to 
that of a split pea, are firm to the touch, and occasionally the small 
papules or nodules are capped with a vesicle or pustule. The lesions 
are prone to remain for a considerable time, then undergo involution, 
leaving a small pigmented scar, which gradually becomes less con- 
spicuous. In some cases involution occurs rapidly when once initiated. 

Folliclis Type. — In this variety the favorite sites are on the 
hands, forearms, feet, and legs, though the face may be attacked. The 
trunk seldom is affected. Here the lesions pursue a more rapid course, 
usually completing their cycle in four to six weeks. They usually are 
noted first as red spots, which later develop into vesicle- or pustule- 
capped papules or nodules. They are firm to the touch and painless. 
The pustules dry into crusts, w T hich reveal on exfoliation small cica- 
trices. While the lesions are usually discrete, patches may occur. 
The disease is chronic in its course. Barthelemy 2 reports a case last- 
ing ten years, which had exacerbations, the patient never being entirely 
free. In the case of a patient recently examined by us the affection 
had lasted four years and appeared worse in the early autumn. This 
case illustrated the fact pointed out by Crocker, that the lesions on the 
fingers are more indolent and firm, and apparently have hard centres 
surrounded by a rim of pus. The disease occurs as a rule in persons 
having tuberculosis or with tuberculous antecedents. 

Pathology. — The symmetry of the lesions and the early involve- 
ment of the bloodvessels point to some irritant brought to the cutaneous 
surface through the general circulation. In different cases different 
anatomical structures are affected more or less severely, which naturally 
alters the histological picture, and has in consequence led to confusion 
in nomenclature. The relationship of the tuberculides to tuberculosis 
generally is conceded, but opinion is divided as to the exact nature of 
this relationship. Histologically, a tuberculous architecture has been 
demonstrated clearly a number of times by different observers. Many 
cases, however, merely show the changes incident to a simple inflam- 
mation. Inoculation experiments have, on the whole, been negative, 
and the presence of Bacillus tuberculosis in the lesions has rarely been 
demonstrated. The vascular changes in these conditions are evidenced 
by an endophlebitis, which often appears as the earliest phenomenon. 

1 Diseases of the Skin, p. 1164. 

2 Quoted by Crocker, Diseases of the Skin, p. 1169. 



682 NEW-GROWTHS. 

Giant-cells and a tuberculous architecture have been demonstrated in 
different members of this group by Galloway, 1 MacLeod, 2 Darier, 
Leredde, 3 Bureau, 4 Little, 5 and others. Pollitzer, 6 Fordyce, 7 Unna, 8 
Dubreuilh, 9 and others have noted special involvement of the coil- 
glands in some cases, but even these Leredde and Bureau consider 
secondary to a granuloma of tuberculous origin. In a histological 
study of two cases, one the acneiform type, the other the so-called 
scrofulous gummata, with MacLeod, of London, we found in both cases 
giant-cells and a typical tuberculous structure, with two tubercle- 
bacilli in the latter. 

Etiology. — In a large number of patients presenting these lesions, 
some form of tuberculosis is present. Sometimes only all hereditary 
tendency is manifest. Again, absolutely no evidence of tuberculosis 
can be demonstrated. While the disease may occur at any period of life, 
the most common age is, according to Fox, between twenty and forty 
years. Recently the tuberculides have been noted often in children. 
Morris 10 has observed that measles is a frequent forerunner of the dis- 
ease. The patients are prone to have a weak peripheral circulation. 
Both sexes are attacked. 

Treatment. — The treatment of the general health is important in a 
majority of these cases. The hygienic surroundings should properly be 
regulated. Fresh air, sunshine, and good food are of prime importance. 
Cod-liver oil, iron, and other tonics, according to the special indications, 
should be used. In the folliclis type Crocker advises thiol, grains 5 
(0.33) three times daily, with applications of 10 percent, vasogen iodin. 
Antiseptic washes, such as boric-acid solution or bichloride of mercury 
(1 : 5000), may be necessary. Excision may at times be employed. 
Mercurial plaster or an ointment containing ammoniated mercury (1 : 30) 
may be applied. Radiotherapy has been of distinct value in two cases 
treated by us. 

" Tuberculous Eczema " (Unna) is merely an exudative affection, 
which may be recognized in proximity to the scrofulodermata, a process 
awakened by the irritative effects of the latter ; or the disease occurs, 
as do other affections, in scrofulous patients. 

Melanoderma of the Scrofulous (Pigmentary Tuberculide). 
— In some of the subjects of scrofula and tuberculosis a hyperpigmen- 
tation of the skin has been produced strongly resembling the pigmen- 
tary syphilide. The coloration is in varying shades of brown, and forms 
a reticulated staining of the regions about the face and neck, though 
other parts may be involved. Between the pigmented spots lighter 
points and dots of a less deeply stained integument are commonly 

1 Brit. Jour. Derm., 1901, xiii., p. 17. 

2 Ibid., p. 367 (report on the Histopathology of Two Cases of Cutaneous Tuber- 
culides, in one of which tubercle-bacilli were found). 

Quoted by Crocker, Diseases of the Skin, p. 1167. 

4 Ibid., p. 1169. 

5 Brit. Jour. Derm., 1901, xiii., p. 185. 

6 Quoted by Unna, Histopathology, p. 399. 

7 Jour. Cutan. Dis., 1891, ix., p. 128. 

8 Histopathology, p. 399. 

9 Arch, de Med. exp£r., et d'Anat. path., 1893, s. 1, v., p. 63. 
10 Diseases of the Skin, 1903, p. 422. 



LUPUS ERYTHEMATOSUS. 683 

visible. The well-known influence of tuberculosis of the adrenals in 
the production of pigment-changes in the skin lends color to the 
belief that some of these cases are due to the toxins of a tuberculosis 
of non-integumentary tissue. Similar pigment-changes in the skin 
have been determined to be the result of paludism, carcinoma, syphilis, 
and other disorders : and it is reasonable to conclude that the changes 
here set down in some instances at least are the product of tuberculous 
toxins. 

Lupus Erythematosus (consult the following chapter) is by some 
authors classed with the disorders grouped under the title of tubercu- 
losis cutis or as a paratuberculosis. The evidence that it is itself a 
cutaneous tuberculosis is wanting. That, however, it is in some cases 
a dermatosis of tuberculous subjects cannot be questioned. 

LUPUS ERYTHEMATOSUS. 

(Lat. lupus, a wolf.) 

(Lupus Sebaceus, Lupus Superficialis, " Scrofulous Ring- 
worm/' Seborrhcea Congestiva, Lupus Erythematodes, 
Lupus Non-ex edens, Ulerythema Centrifugum. Fr., 
Scrofulide Erythemateuse, Erytheme Centrifuge.) 

This disease was first described by Biett under the title Erytheme 
Centrifuge. Hebra, in 1845, described it among the seborrheas, as 
Seborrhcea Congestiva. Its present title was given by Cazenave in 
1850. 

Symptoms. — The disease is first exhibited in one or several rape- 
seed- to bean-sized, slightly elevated reddish macules which do not 
entirely fade under pressure and are covered with a grayish or yellow- 
ish and sometimes slightly greasy, adherent scale. 

In the ordinary Discoid form of the disease the primary lesion 
described above enlarges its periphery in the course of months or years 
by a slowly continuous development. It may thus gain the size of a 
small coin or a large saucer. The disks or patches are well defined 
in outline, of a color varying with the complexion of the patient and 
with the acuteness or type of the disease, from a rosy-pinkish to a deep- 
purplish hue. The shape is usually circular, oval, or in figures rep- 
resenting combinations of these outlines, but it may be irregular from 
the junction of two or more progressing patches. Its border is red, 
firm to the touch and distinctly elevated, and not infrequently exhibits 
comedones or light adherent scales. The centre is depressed, paler in 
color, and shows either adherent yellowish-gray scales or a glistening 
unbroken epidermis. Close examination will disclose in most cases 
dilated follicular openings which may be plugged with dried sebaceous 
matter or horny epithelium. The scales vary in color, being at times 
of a clear white or whitish yellow, and again often from concurrence 
of comedones of a reddish or brownish tint. They are usually scanty 
and adherent, but may be abundant, and occasionally can be seen 

1 For complete bibliography, see Jadassohn, Mracek's Handbuch, vol. iii., p. 416 
(more than five hundred references). 



684 



NEW-GROWTHS. 



firmly fastened to the orifice of the excretory duct of a sebaceous gland 
by means of a horny projection from the under surface. In some cases 
the erythematous redness, in others the crusted surface of the disk, is 



Fig. 73. 




Lupus erythematosus of the face, 

the most pronounced feature. In the latter there are seen at times 
patches exhibiting almost a pure type of seborrhoea faciei. 

The disease is seen most frequently on the nose and cheeks, over 
which it may spread symmetrically in a form that has been likened 
by Hebra to the open wings of a butterfly. It occurs also on other 
parts of the face, the ears, the scalp, the back of the hands and ex- 
ceptionally on other portions of the body. On the scalp the dilated 
follicles and comedones are especially pronounced, while the elevated 
border is rather less distinct than on the face. The alopecia which 
results is permanent. Rarely the mucous membrane may be involved, 
presenting reddened plaques with minute excoriations, or partially cov- 
ered with a whitish exudate or with punctate scars. 

As the borders advance the centre not infrequently undergoes invo- 
lution, and may show typical scars even while the outer rim is actively 
progressing. When the disease undergoes general involution both the 
centre and the border gradually become paler in color and less ele- 
vated. Some of the patches resolve without leaving a trace of their 
existence, but in most instances typical scars are left. These are in- 
delible and characteristic. They are generally uniform and superficial, 
can be pinched up readily between the thumb and finger, are of a dull- 



LUPUS ERYTHEMATOSUS. 685 

whitish tint, and rendered punctate in a peculiar manner, suggesting 
the action of the engraver's tool in what is known as the " stippling " 
process. They are never pigmented, puckered, radiate, stellate, corded, 
or deeply attached. 

The disease is remarkably chronic in its course, lasting in cases for 
a quarter of a century or even longer, and throughout not interfering 
with the general health. So-called " galloping cases," usually with 
marked visceral complications, are described by French writers. The 
disease varies in the subjective sensations it produces, being generally 
accompanied by no discomfort, though at times by some itching or 
burning. It is more common in women than in men, and is a disease 
of adult years, usually appearing first in the third or fourth decade. 
Kaposi reports a single case in a child three years of age. 

Though the disease usually progresses by a very slow extension of 
the border, it may, after remaining comparatively stationary for months 
or years, rapidly advance for a short period and then again remain sta- 
tionary. These periods of rapid progression usually follow or are 
accompanied by a peculiar type of acute dermatitis suggesting a mild 
form of erysipelas. 

Among the unusual features of the disease may be mentioned an 
acute form, named by the French Erytheme Centrifuge, which has 
most of the characteristics described above, except that the symptoms 
are more acute and the vascular elements more marked. This condi- 
tion may disappear, leaving the skin entirely normal, or it may be fol- 
lowed by the more common type of the disorder. The reddened 
plaque has been by several authors likened to the lesions of exudative 
erythema, being hot to the touch, tender, raised, and manifestly cen- 
trifugal in its mode of extension. 

The Telangiectatic form is occasionally seen. Here points, spots, 
plaques, or large disks on the surface, chiefly of the face, usually well 
defined, present a rosy-reddish, or deep-purplish color which disap- 
pears under pressure. When examined with care the color is seen to 
be due to dilatation of the cutaneous vessels. The surface may be 
either slightly cedematous, or infiltrated, and correspondingly elevated. 
There is an absence of scaling and of dilated follicles, but typical scars 
not infrequently follow the involution of this type of the disorder. 

Lupus Disseminatus. — The disease occasionally occurs in a dif- 
fuse form. As a rule, the lesions first appear on the face, but later 
they develop on any part of the body, and often large surfaces are 
involved. The lesions are small, varying in size from that of a pinhead 
to that of a bean, and though usually presenting characteristics similar 
to the beginning patches of the more common type, they may assume 
atypical forms resembling the lesions of erythema multiforme, urticaria, 
syphilis, acute psoriasis, or pityriasis rosea. At times the subjective 
sensations are severe (itching, burning, heat, etc.), and the patches may 
even be the seat of vesicles, pustules, or bullae. This form of the dis- 
ease is accompanied in most instances by such systemic disturbances 
(arthritic, gastro-intestinal, and febrile) as occur in erythema multi- 
forme. In rare instances there are changes suggesting erysipelas, some- 
times accompanied by typhoid and other malignant symptoms. This 



686 NEW-GROWTHS. 

condition was designated by Kaposi as erysipelas perstans faciei, and 
he reported that in 50 per cent, of the cases death resulted. 

Lupus Pernio l is another unusual form in which the lesions are 
exhibited on the fingers and toes particularly, but also on other parts 
of the hands and feet and on the pinna of the ear, beginning as a more 
or less persistent erythema of the type of pernio (chilblain). Like the 
latter disease, this erythema may disappear and reappear with the 
seasons for several years, but eventually may persist and assume the 
discoid type. 

The Livedo Form. — A rare subvariety is recognized on the face, 
hands, and other regions where the symptoms present the character 
of local asphyxia. Here the influence of the trophic nerves, as in 
other conditions with similar symptoms, is distinct. The disease begins 
with the production of livid spots in the regions named, which persist 
for months or even years, and eventually degenerate at the centre, 
leaving a slough beneath which is an ulcer. In these cases, also, tuber- 
culous complications may occur in the joints. 

Etiology. — Lupus erythematosus is described by some writers as a 
variety of lupus vulgaris, but the histopathology of the former disease, 
the absence of tubercle-bacilli, and the negative results of many inocu- 
lation-experiments seem sufficient to disprove such relationship. The 
transitional forms occasionally reported usually prove to be mild and 
unusual types of lupus vulgaris. 

Although lupus erythematosus has none of the essential character- 
istics of a local tuberculosis, it occurs not infrequently as a dermatosis 
of the tuberculous. Besnier was the first to call attention to the fact 
that lupus erythematosus is in many instances associated with general 
or local tuberculosis. Cases in which this association occurred have been 
reported by a number of observers. Boeck 2 records forty -two cases of 
the common discoid type, in twenty-eight of which he found evidences 
of present or past tuberculosis. Roth 3 collected records of two hundred 
and fifty cases of lupus erythematosus, in one hundred and eighty-five 
of which evidence of local or general tuberculosis could be obtained. 
In such cases Boeck concludes that the toxins of the tubercle-bacillus 
act first upon the vasomotor centres of the skin and later upon that 
portion of skin which is the seat of the vasomotor disturbance. 

Tuberculosis should thus be counted as an important factor in the 
etiology of lupus erythematosus, but that it is the sole cause or even 
an essential factor has not been demonstrated. It is associated more 
frequently with the disseminated than with the discoid forms of the 
disease. Pick, 4 after studying the effects of tuberculin injections in 
twenty-nine cases, concluded that lupus erythematosus discoides is not a 
manifestation of tuberculosis. Sequeira and Balean 5 , after an investi- 

1 Cf. contributions to this subject by one of us, Jour. Cutan. Dis., 1884, ii., p. 321, 
and by Ohmann-Dumesnil, Ninth Internat. Medical Congress, 1887. 

2 Archiv, 1898, xlii.,p. 71. 

3 Ibid., 1900, li., p. 3. 

4 Ibid., 1901, lviii., p. 358 (bibliography). 

5 Brit. Jour. Perm., 1902, xiv., p. 367 (bibliography), 



LUPUS ERYTHEMATOSUS. 687 

gation of seventy-one cases, agree with Pick regarding the discoid 
variety, but found tuberculosis frequently associated with the dis- 
seminated form. They found albuminuria in one-half of the cases of 
this type. 1 The disease is seen frequently in individuals in whom there 
is no history or other evidence of tuberculosis in any form. It occurs 
in conjunction with anaemia, chlorosis, and other disorders. In many 
patients careful investigation fails to discover any other evidence of ill 
health. By some writers the disease is considered a chronic inflamma- 
tion due to a specific infection. 2 

The disease is more common in women than in men, two-thirds of 
the former to one of the latter, and usually appears first in the third 
decade of life, in this particular presenting a contrast with lupus 
vulgaris. It may, however, first develop in childhood, middle life, or 
old age. 

Lupus erythematosus may follow eczema seborrhoeiicum, acne, undue 
exposure to sunlight, variola, erysipelas, vesication with cantharides, 
or the traumatism of leech-bites. It may appear where the curette 
has been employed in a patient with a characteristic patch elsewhere 
on the face. It occasionally develops on portions of the face and hands 
that have been subject to recurrent attacks of pernio. 

Pathology. — Lupus erythematosus has been studied carefully by 
a number of observers, but unfortunately they do not agree either in 
their histological findings or in their conclusions based upon the 
latter. In general it may be said that the chief changes are found 
in the upper half or third of the corium in the form of a dense infil- 
tration of small round cells of embryonic type, a small proportion of 
which is probably the result of proliferation of the fixed cells of the 
part. The infiltration varies greatly in extent and in density in dif- 
ferent types of lesions, but is most pronounced along the course of the 
vessels. It is often found in slight degree in the deeper parts of the 
corium and subcutaneous tissue ; but it nowhere forms nodules as in 
lupus vulgaris ; there are no giant-cells ; and there is no degeneration 
of a mass of cells as in the latter disease. Individual cells here and 
there undergo a granular and fatty or colloid degeneration, disappear 
by absorption, and are replaced by new cells. The connective-tissue 
fibres are destroyed in the same way. Many of the vessels are seen 
to be greatly distended and choked with red blood-corpuscles, others 
show a proliferation of their walls and in some cases an obliterating 
endarteritis. Diffuse or localized hemorrhages are found in the upper 
part of the cutis. By some observers the vascular changes are con- 
sidered primary in the process. The sebaceous glands are at first 
hypertrophied, affected with hypersecretion, and become filled with cells 
and abnormal sebaceous matter. Later both they and the ducts of the 
coil-glands may become infiltrated, undergo degeneration and dis- 
appear, leaving the peculiarly punctate form of scar characteristic of 
the disease. 

1 Brit. Jour. Derm., 1903, xv., p. 249. 

2 Galloway and MacLeod, Brit. Jour. Derm., 1903, xv., p. 81, believe that lupus 
erythematosus, like erythema multiforme, may be due to toxaemias arising from various 
causes. 



688 NEW-GROWTHS. 

The epidermal layers are involved secondarily. They become 
atrophied, and the interpapillary depressions of the rete as well as the 
papillae are largely obliterated. 

Fordyce and Holder 1 investigated a number of cases of the discoid 
type and describe a peculiar blocking of the capillaries with blood-cells 
which they believe to be the primary change. They divide the factors 
making up the histopathological complex into the round-cell infiltra- 
tion, the peculiar degenerated condition of connective tissue, and the 
secondary atrophy. They find that the commonly described fatty and 
granular degeneration is not characteristic of the process, and recom- 
mend that for purposes of study tissue from lupus erythematosus areas 
be imbedded in paraffine and stained with acid orcein. Schoonheid, 2 
from a histological study of twelve cases, concluded that lupus erythe- 
matosus is a chronic inflammatory process, and describes a peculiar 
degeneration and destruction of the elastin, which he believes to be the 
immediate cause of the superficial scars. 

Robinson, 3 after examining a number of cases and reviewing the 
published reports of others, states that the primary lesion, which 
may be seated in any part of the corium, is focal in character, and 
when fully developed constitutes a new-growth, which is reticular in 
structure and closely connected with the lymph-channels. He con- 
cludes that " lupus erythematosus is a chronic inflammatory disease of 
the cutis with special histological characters, as shown by the changes 
in the blood-vessels — new blood-vessels in the affected area, lymph- 
vessels and lymph-channels, and the new-formation of an adenoid-like 
tissue — by reticular tissue, by the presence of mononuclear and by the 
absence of polynuclear cells in the cell-infiltration; and that these 
changes must depend upon the presence of a poison generated in loco. 
In other words, lupus erythematosus is a local infective process — a 
granuloma." 

Diagnosis. — The facies of the patient with lupus erythematosus of 
that region is usually so characteristic that the disease is there recog- 
nized with ease. When the hand and other portions of the body are 
involved the diagnosis is somewhat less readily established. In the 
hand the disease has a predilection for the dorsum, and invades the 
palm usually only by extension to it from behind. 

From lupus vulgaris erythematous lupus may be recognized by its 
occurrence originally at a later period of life; by its greater tendency 
to symmetry; and by the absence of nodules, ulceration, and extension 
to the deeper portions of the skin or underlying structures. Cases 
undoubtedly occur in which the diagnosis is difficult, as in the type 
called by Leloir lupus vulgaris erythematoide. But as in all cases 
of lupus vulgaris typical nodules appear sooner or later, the diagnosis 
can eventually be established. 

In eczema there is usually some history of moisture ; in erythema- 
tous lupus, rarely. In eczema, also, the itching is a more persistent 
and distressing symptom ; but the acuteness of even chronic eczema, as 

1 K Y. Med. Kecord, 1900, lviii., p. 41. 

2 Archiv, 1900, liv., p. 163. 

3 Trans. Amer. Derm. Assoc., 1898, p. 70. 



LUPUS ERYTHEMATOSUS. 689 

compared with lupus erythematosus, will suffice to distinguish the two 
diseases. From eczema seborrhce'icum, however, the diagnosis may be 
difficult and may have to depend on a therapeutic test, the latter dis- 
ease disappearing under appropriate treatment. Psoriasis is rarely, if 
ever, limited to a single patch on the face; it is also characterized by 
more lustrous and more readily exfoliating scales. Its patches are, 
furthermore, uniformly well covered with scales, and are of equal flat- 
ness in all parts, while those of lupus erythematosus are irregularly 
squamous, the scales being often clustered at the orifices of the ducts 
of the sebaceous glands, while the rim of the patch is elevated and the 
centre depressed. From pernio the diagnosis sometimes can be made 
only after determining whether the lesions disappear during the warm 
season, as in pernio ; or persist, as in lupus erythematosus. 

In acne rosacea there are marked telangiectases and papulo-pustules 
or nodules which are not found in erythematous lupus. In tinea cir- 
cinata there may be a clearing, but never a cicatriform centre of the 
circular disk. The circular serpiginous syphilodermata of the face 
occur usually with other manifestations of lues, are characterized by 
greater infiltration, a more rapidly progressing border formed by the 
coalescence of individual papules or tubercles, and in most cases the 
syphilitic lesions exhibit distinct signs of ulceration. The not infre- 
quent modification or masking of a patch of the disease by an acute or 
subacute dermatitis (often seborrheal in character) should be borne in 
mind. 

Treatment. — The internal treatment of this affection is not highly 
satisfactory ; often none is indicated or required. Of course, the general 
health of the individual should be carefully investigated, and all defects 
remedied if possible. The administration of potassium iodide, mercuric 
iodide, iodoform in 1 grain (0.06) doses (Whitehouse), starch iodide, 
arsenic, iodoform, ammonium carbonate, ichthyol, sodium salicylate, and 
many other remedies have been advocated by different writers. It is 
doubtful if these articles ever do good unless indicated by the patient's 
general condition, while they often do much harm. The last three 
remedies on the list given above are said by Fox, Unna, and others, to 
lessen the congestion of the face. When they do produce this effect it 
is possible advantage may be derived from their use. 

The number of remedies recommended for local use in lupus 
erythematosus is enormous. White, 1 in reviewing the subject, has 
enumerated some fifty of those most promising, at the same time 
calling attention to the fact that lupus erythematosus is no exception 
to the rule that " the curability of a disease is in inverse ratio to the 
length of the list of the means recommended for its cure." He 
admits that our treatment of this disease is wholly empirical, and not 
very hopeful. Unna 2 attempts a rational form of treatment based on 
his conception of the etiology and pathology of the disease and of the 
action of certain remedies. While his scheme is based largely on 
theories that are not yet capable of demonstration, the details of his 
treatment are of practical value. He calls attention in particular to the 

1 Jour. Cutan. Dis., 1898, xvi., p. 457, 

2 Ibid., p. 465. 

44 



690 NEW-GROWTHS. 

fact that while the epidermis is exceedingly dry and hyperkeratotic, the 
cutis is markedly oedematous and the seat of dilated lymph-spaces and 
channels, and emphasizes the dangers of stimulating a dry indolent 
process into an active dermatitis. 

For convenience, the remedies used may be divided into three 
classes : the soothing and astringent, the stimulating, and the destruc- 
tive. The choice of remedies will depend largely upon the type of 
the disease and on the character of the individual skin. In the acute, 
inflammatory, or vascular type soothing remedies alone should be used, 
and on a skin which reacts readily to stimulation stronger remedies 
are not allowable. Nor should it be forgotten that the indolent forms 
of the disease not infrequently under treatment become acutely in- 
flamed, and call for the temporary use of soothing measures. Inas- 
much as the affection is one the involution of which occasionally is ac- 
complished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequels, the simpler measures should 
always be adopted first. In the way of soothing and astringent prep- 
arations, the lotions, powders, simple ointments, and pastes recom- 
mended for the treatment of acute eczema can be employed to advan- 
tage. The zinc oxide powders and lotions are especially to be com- 
mended, as are also the cold-cream salve, the Hebra, and the zinc oxide 
ointments. The paste containing equal parts of lanolin, vaselin, zinc 
oxide, and talcum makes an excellent base. Boeck's liniment (talci, 
amyli, aa sijss (10.); glycerin., 3j (30.); aq. plumbi, £v (160.); and 
Unna's " pulvis cuticolor " (zinc, oxid., boli rubrse, aa, 2 ; boli albse, 
magnes. carbonat., aa, 3 ; amyl. oryzse, 10) are valuable preparations 
in acute and irritable stages of the disease. 

Frequently much can be accomplished through protection and com- 
pression of the surface by the application of collodion, the glycogela- 
tins, or tragacanth-jelly. Unna recommends especially for irritable 
cases : 



R 



R 



Ichthyol. (vel ichthyol. sulfon.), 
Collodii, 


3ss; 
3v; 


21 
20| 


idolent cases : 






Saponis virid., 
Collodii, 


3ss-ij ; 
3v; 


2-4! 

20 1 



M. 



M. 



To the latter may be added 1 or 2 parts of salicylic acid. 

Unna recommends also gelanthum as a substitute for collodion in the 
above formulae, for though it does not produce as much compression 
as the latter, it is more convenient in that it may be washed off at any 
moment with warm water. A favorite formula with him is potass, 
hydrat., 1 ; gelanthum, 1000. 

For the purpose of producing more or less stimulation of the sur- 
face there may be added to the lotions, ointments, and pastes suggested 
above, from 2 to 20 per cent, of sulphur, or from 1 to 5 per cent, of 
salicylic acid, white precipitate, resorcin, ichthyol, or tar. The mild 
salicylated soap plasters or the plaster-mulls containing the above 
remedies in small amounts, or a reduced mercurial plaster may be 



LUPUS ERYTHEMATOSUS. 691 

used where a moderate amount of stimulation is desired. Excel- 
lent results follow the use of green soap applied as a plaster or in the 
form of tincture. It not only cleanses the patches of the scales, but 
also stimulates the surface, often to the extent of inducing a repara- 
tive process. The patch may be briskly rubbed either with soap or 
tincture of soap in combination with hot water, after which a simple 
ointment or one containing a small amount of sulphur or other of the 
remedies suggested above may be applied. When decided irritation 
of the parts is produced, the soap should be discontinued and the hot 
water and ointment be employed alone for a time. A decidedly bene- 
ficial effect is noted occasionally after the topical application, for 
twenty minutes at a time, of very hot water alone. After drying, the 
surface should be dusted with a powder or covered with a simple oint- 
ment or paste. 

The following is a gentle stimulant : 

R Zinci sulphat., } ,: -,. 

iuret., \ aa 3ss, 



Potassii sulph 

Spts. vin. reel if., f 3iij ; 12 

Aq. rosse, f^iijss; 105 

Sig. To be diluted as required for external use. 

The following is a formula for a stronger lotion : 



R Chrysarobin., 

Acid, salicylici, ) 

Calaminis pulv., } 

^Etheris, 

Collodii flex., 
Sig. To be applied with a brush. 



M. 



Sijss ; 


10 


aa £ss; 


aa 2 


f33; 

f3v; 


4 
20 



M. 



The non-vascularized, indolent varieties of erythematous lupus are 
often treated with very satisfactory results by the topical application of 
a saturated solution of pyoktanin-blue. This method has the great 
disadvantage of producing a deep bluish stain of the face, but the dis- 
figurement is willingly tolerated for a brief period by patients who have 
long suffered from the facial unsightliness of the disease itself. The 
solution is thickly painted daily over the entire portion affected ; and 
the application usually may be made by an unskilled hand. No pain 
is produced and no untoward effect of any kind has been noted. The 
applications have been repeated continuously for sixty days and more 
with excellent results. 

Enzymol painted over each patch several times in the day has been 
followed in some cases by marked improvement. 

Hans Hebra 1 applies several times daily alcohol on cotton pads. 
The evaporation of the spirit and abstraction of water produce the 
beneficial effect. 

Lupus erythematosus has been treated successfully with photo- 
therapy and with radiotherapy by a number of observers, including 

1 Wise, caed, Wchnschrft., 1899, xlix., p. 13, 



692 NEW-GROWTHS. 

Finsen, Leredde and Pautrier, Gastou, Moris and Dore, Pusey, and 
ourselves. 1 We have treated twenty-eight patients with lupus ery- 
thematosus by the two methods, employed singly or in combination. 
Of these, five are well, and have remained free from the disease for 
periods varying from eight months to two years. Another was relieved 
entirely of symptoms, but the disease recurred after four months. 
Eleven are nearly well, the disease having disappeared entirely from 
some areas and being much less conspicuous in others. Three show 
great improvement. Eight show some progress toward recovery, 
though they have received treatment irregularly or for a short time 
only. Of the twenty-eight cases, there is none which has not event- 
ually shown some improvement under treatment. 

In our experience, the lesions in which the vascular element pre- 
dominates or which are subacute in type do better with phototherapy 
than with the £-rays, which in one such case caused an aggravation 
of the symptoms. We have seen no such unfavorable effects from 
phototherapy as are reported by Sequeira and MacLeod in acute stages 
of the disease. Lesions with marked infiltration and decided involve- 
ment of the glands and follicles resist the light treatment and improve 
more rapidly under the ic-rays. 

These two methods certainly promise better results in lupus erythe- 
matosus than have been obtained by other measures, though it is too 
early to pass on the permanency of the results obtained. 

In exceedingly obstinate cases, those especially in which the elevated 
rim of the erythematous disk refuses to yield to the simple measures 
described, a solution of caustic potash in distilled water, 1 part to 2 or 
4, may be gently applied with a camel Vhair brush, and the alkali 
immediately neutralized by the addition of dilute muriatic acid as soon 
as the desired effect is produced. That effect, it must be remembered, 
is superficial cauterization only. When the sero-sanguineous exudation 
and reactive effects disappear the rim is seen to be flattened and to have 
lost in part its violaceous blush. After such severe application, which 
should never be trusted to the hand of one unskilled in its use, an 
anodyne cerate containing morphine or opium should be spread over 
the part. 

In indolent patches where decided stimulation or even a very super- 
ficial destruction of tissue is desired, mercurial plaster, the stronger 
salicylated soap-plasters, and plaster-mulls are to be recommended, or 
creosote, carbolic acid, thilanin, chrysarobin, pyrogallol, salicylic acid 
and pyrogallol (1 part of the first and 3 of the second to 40 parts of 
flexible collodion, Brocq), silver nitrate, lactic acid, or Fowler's solution 
may be used. Two drachms (8.) each of iodine and potassium iodide 
mixed with 4 drachms (16.) of glycerin ; or equal parts of chloral, 
tincture of iodine, and carbolic acid, are recommended highly. These 
stronger remedies, however, are to be used with great caution and Only 
in indolent cases, and then only after milder measures have failed to 
produce good results. 

Where more extensive destruction of tissue is required caustics are 
applied, as carbolic, lactic, pyrogallic, or chloracetic acid. A strong 

1 See paper by one of us, Jour. Cutan. Dis., 1903, xxi., p. 529 (bibliography). 



SYPHILIS. 693 

solution of potassium hydroxide or mercuric nitrate, or an arsenical 
paste, may be employed. 

In a few cases electrolysis has been of benefit. Erasion with a 
dermal curette, as well as operation by multiple punctures or by linear 
scarifications, is of less value than in lupus vulgaris. Erasion has in 
some instances been followed by involution of the disease, but also, 
as a rule, by cicatrices that are no less disfiguring than the original 
disorder. 

Prognosis. — A favorable opinion with respect to the future of the 
disease never can be given safely, but with improved technique a large 
percentage of cases should be amenable to treatment with phototherapy 
and radiotherapy. The general health and comfort of the patient 
suffer rarely. The affection is capricious in its course, and may on 
occasions, after long periods of persistence, rapidly improve under the 
simplest treatment. Spontaneous involution, with disappearance of all 
symptoms, is reported in some cases. The disorder is liable to relapse, 
though not to frequent recurrence. Its tendency to the production of per- 
sistent scars should always be remembered in formulating a prognosis. 

SYPHILIS. 

(Gr. avg and tyilog, a companion of swine : term coined for poetical purposes by Fra castor.) 

(Lues Venerea, Morbus Gallicus, Pox, " Bad Disorder." Ft., 
Verole; ItaL, Sieilide; Ger., Lustseuche, Krankheiten 
der Franzosen; Span., Sifilis; Swed., Radezyge.) 

Syphilis is a chronic and infectious disease not yet actually demon- 
strated as having a microbic origin, but its position among the infec- 
tious granulomata practically is established. The presence of micro- 
organisms, supposed to be effective in the production of the disease, 
has been recognized by the several observers named in the paragraphs 
devoted to the pathology of syphilis. These bacteria have been found 
in papules, nodes, chancres, and secretions from syphilitic lesions, but the 
strict requirements of science as to proofs of their'etiological value have 
not been satisfied. Whether these micro-organisms or others are demon- 
strated finally to be the potent agency in producing syphilis when it is 
transmitted by the medium of a virus, it is at least certain that late 
investigations into the nature of lepra and tuberculosis lend strong 
support to the doctrine that the contagium of syphilis is due to the 
presence in its secretions of a species of bacterium. 

Syphilis has been described as an " imitator of other diseases." 
The manifestations of the malady are certainly protean in character, 
and they may occur in every organ and tissue of the body. These 
phenomena are both like and unlike the symptoms of non-syphi- 
litic diseases of such organs and tissues. It would, therefore, be more 
in accordance with facts to describe syphilis as a special mode of dis- 
ease. Its phenomena differ from other pathological phenomena chiefly 
in the syphilitic modality with which they are impressed. After 
infection there is a different behavior of the living matter of which the 
body is constituted. Its mode thenceforward is temporarily changed as 



694 NEW-GROWTHS. 

regards the process of disease. Hence the importance of recognizing 
this modality in relation to disease of the skin, and of ascertaining 
the limits within which this influence is both originated and exhausted. 

Ricord was first to classify the phenomena of syphilis in three dis- 
tinct stages. In the first stage, or primary syphilis, were included 
symptoms relating to the chancre and its accompanying adenopathy. 
In the second stage, lasting from the date of the onset of general 
syphilis during a period of about two years, were grouped symptoms 
that were, as a rule, superficial, symmetrical, and more or less tran- 
sitory. In the third, or tertiary, stage the symptoms included were, 
as a rule, asymmetrical, more profound, involving the subcutaneous 
and deeper tissues, and invading often not merely the skin, but also 
the osseous, cartilaginous, and other structures of the body, including 
the viscera. This simple scheme when first given to the scientific 
world revolutionized all previous conceptions of the disease, and has 
dominated the medical profession up to the present time. 

But there are objections to a continued acceptance of this scheme, 
based largely on its incompleteness. The distinctions it seeks to make 
are wholly artificial, are defined by poor limits, and so often are com- 
pletely negatived that they fail to explain the most important of accidents. 
To be consistent and to explain in part the violations of their time- 
schedule, the French have coined such phrases as " precocious," " tardy," 
" galloping," etc. Further, the mind once dominated by this scheme 
was educated to look for the evolution of symptoms within each of these 
artificial stages in a determinate order, e. g., after the occurrence of 
macules succeeded papules ; after these, pustules, tubercles, etc., a 
progression rarely observed in any given case. 

The Symptoms of syphilis are best studied, as they are clinically 
displayed in distinct departures from the infection-moment, along lines 
which are not fixed, but between which symptoms are intermingled with 
varying shades of severity. The four chief classes which may thus be 
recognized include most of the clinical pictures of syphilis : 

I. Benignant Syphilis, with Superficial and Transitory Symptoms. — 
In this first class the skin-lesions of general syphilis are few and at 
times are even insignificant. A macular rash, for example, over the 
surface of the chest and belly, lasting for a few days or for a week or 
more, accompanied by ganglionic enlargement, after involution, leaves 
the patient for the remainder of life free from obvious signs of the 
malady. These instances are rare. 

II. Benignant Syphilis, with Superficial and more or less Persistent 
Symptoms. — In this class are to be catalogued most cases of the disease. 
Some cases relapse to it from the class previously described ; others, 
fewer in number, retrograde to one of the groups named below. There 
is throughout no cachexia, and the skin-symptoms of the affection are 
neither destructive nor deep. Their chief significance lies in the fact 
that they may persist or may recur until the disease, either as a result 
of treatment or of a decline due to other causes, ceases to manifest itself 
by any symptoms whatever. 

III. Malignant Syphilis, with Profound, Relapsing, or Persistent 
Symptoms that Ultimately Resolve. — In this group are collected those 



SYPHILIS. 695 

cases in which, with persistent or with recurrent symptoms gradually 
involving the deeper structures of the body, the system suffers to the 
extent of exhibiting the signs of cachexia. Patients in this class, by 
reason of efficient treatment or the reverse, are readily transferred both 
to the second class and to the fourth. 

IV. Malignant Syphilis, with Profound and Relapsing, or Persistent 
Symptoms that are Ultimately Destructive. — In this class are included 
the gravest forms of the disease : those exhibiting deep and destruct- 
ive cutaneous lesions ; those implicating the viscera, bones, and other 
structures ; those interfering with the integrity of organs by reason 
of either atrophic or degenerative changes succeeding a circumscribed 
or gummatous involvement of tissue. 

No one of the groups of symptoms named above necessarily follows 
any other. The last-described group may occur within a few months 
after the appearance of so-called " primary syphilis," even though 
formerly included in the old nomenclature among those of late, or ter- 
tiary, type. Many cases, indeed, of grave syphilis are of the type de- 
scribed by the French as " precocious " ; that is, they develop symp- 
toms of gravity either before or soon after the healing of the chancre. 

Chancre. 

Every attack of acquired syphilis exhibits as a first symptom an 
infecting chancre, and every infecting chancre signifies syphilis. 

A chancre is that modification of the sound or of the pathologically 
altered skin or mucous membrane, preceded by a period of incubation, 
characterized by sclerosis, and accompanied by adenopathy, which con- 
stitutes the initial lesion of inevitable syphilis. Chancres usually appear 
upon or about the genital organs simply because these organs are most 
often exposed to the disease. These lesions may, however, occur upon 
any portion of the surface of the body. 

Chancres appear after a period of incubation — an interval of time 
between the date of exposure to the disease and the manifestations of 
its first symptom. This period averages twenty-one days, but it may 
extend from ten days to two months and even more. 

The chancrous modification may involve, as stated above, the nor- 
mal or the pathologically altered skin or mucous membrane. Upon 
previously sound surfaces chancres may appear, after an incubative 
period, as macules, papules, tubercles, erosions, fissures, or ulcers, each, 
or either of which, at some future period of its history is character- 
ized by a peculiar hardness of the tissues about and beneath the lesion, 
this condition being known as the " initial sclerosis." These symptoms 
vary according to the location of the chancre and the friction or other 
external irritation to which the lesion has accidentally been subjected. 
Generally it may be said that all chancres tend to conform to the 
papular type, the macule developing into the chancrous lesion, the 
tubercle being evolved from its exceptional enlargement, the ulcer 
from its degeneration, and the erosions or fissures from the accidents 
of its less pronounced features. Occurring upon mucous or quasi- 



696 



NEW-GROWTHS. 



mucous surfaces these lesions are influenced by heat, moisture, and 
friction (labia, prepuce, etc.). Here the superficial erosions are usually 
circular in outline, are very slightly depressed, and they rest upon 
delicate beds of sclerosed tissue, the so-called " parchment-induration." 
The papule is often represented by a tolerably well-circumscribed, 
macular discoloration of the membrane, where coarse examination 
would scarcely suggest elevation of the surface, with a sclerosis of no 
greater extent than that of the erosion, with which it probably sustains 
a close relation. As a result of heat, moisture, and friction, however, 
the typically dry and scaling papule constituting the chancre of the 
integument is here rarely encountered. More often the lesion is a 
circumscribed ulcer with clean-cut walls, penetrating deeply to the 
derma or even below, with a scanty secretion and a reddish floor, rest- 
ing upon a split-pea-sized mass of sclerosed tissue. Other usual forms 
are superficial erosions, in themselves of insignificant aspect, surmount- 
ing large nodules, tubercles, or even long linear ridges of densely 
sclerosed tissue, undergoing repair or degenerating according to the 
condition of the patient and the treatment to which he has been sub- 
jected. These erosions are usually out of proportion to the size of 
the indurated mass upon which they rest. Such voluminous indura- 
tions are occasionally perforated by deep conical or funnel-shaped 

Fig. 74. 




Chancre of the tongue. 

ulcerations of formidable aspect, to which the name "Hunterian 
chancre " was once applied. 

Occurring upon cutaneous or mucous surfaces, where there has been 
a previous morbid process, the syphilitic mode is impressed upon the 
symptoms significant of such antecedent disease. This accident is 
sufficiently common, and the resulting lesions are as various as are 



SYPHILIS. 697 

those of different diseases. Thus, a man or woman may be infected 
with syphilis at the site of an herpetic vesicle upon the lip or the 
genitals, such vesicle being unbroken and recent, or several days rup- 
tured ; or at the site of a balanitis ; or of a vegetation ; or of the soft 
contagious sore of the genital region best recognized under the term 
" chancroid." Or the inoculation may occur at the site of a trauma- 
tism ; for example, where the frenum is slightly torn in coitus, or where 
the bruised knuckle of the accoucheur is exposed during the practice 
of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short- 
lived, persistent or recurrent, and in this respect may resemble the 
chancre itself, which may endure but for a few days, or be in course 
of full evolution at the date of appearance of so-called " secondary'" 
symptoms. 

As a consequence, the ganglia in anatomical connection with the 
chancre become, with very rare exceptions, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy ; with labial chancres, submaxillary adenopathy ; with 
chancres of the eyelid, pre-auricular adenopathy, etc. The glands 
usually enlarge within a few days after the appearance of the chancre, 
and remain in that condition for several months. They are indurated 
on one or on both sides of the body ; are freely movable ; are unattached 
to surrounding tissues ; are neither painful, tender, nor inflammatory, 
and they therefore terminate neither by suppuration nor by ulceration. 
It will thus be evident that the word " chancre " is applicable only to 
certain features assumed by other lesions, and is not itself descriptive 
of a lesion differing absolutely from all others. It is indeed clear that 
there can be no particular chancre-lesion, since in turn the macule, 
vesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, and fissure 
may each become a chancre. Every other elementary lesion of the 
skin, therefore, may assume the chancrous features ; in other words, 
may display in its morbid career the modality of syphilis. These 
chancrous features are : infection ; sclerosis after an incubative period ; 
coincident or consequent adenopathy (sclerosis of neighboring ganglia) ; 
and, after a second incubative period, the occurrence of the symptoms 
of general syphilis. The last-named is, of course, an historical feature, 
not recognizable during the greater part of the life of most chancres. 

The minor chancrous features are less constant and trustworthy. 
Chancres of the skin may be deeply pigmented. Some are painful 
from the occurrence of inflammation ; some are injured by traumatism 
(chancre of the nipple in nursing-women) ; some, by irritants (caustic 
improperly applied) ; some, finally, are so insignificant in feature 
(chancre of the vagina) that even the expert is readily deceived in their 
recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a so-called 
" second period of incubation." This period extends usually from 
between the end of the first to the end of the second month after the 
appearance of the chancre, the average being between the fortieth and 



698 NEW-GROWTHS. 

the forty-fifth day. During this period the general condition of the 
patient is that which, by subjective and objective phenomena, displays 
signals of the approaching distress of the economy. There are anaemia, 
and, in cases, even chloro-ansemia ; wandering pains, substernal or 
about the articulations ; a cachectic appearance ; engorgement of the 
superficial and deep ganglia ; occasionally a well-marked febrile pro- 
cess, the so-called " syphilitic fever " ; and a special irritability of the 
skin and mucous membranes. 

The so-called " periods of incubation " in syphilis do not, however, 
really exist. The words used to define them refer to periods of time in 
which, upon gross inspection, the evolution of the disease does not seem 
to be in progress, but in the course of which there is ample evidence that 
there is a gradual involvement of one portion of the body after another. 
Thus, in the " second incubative period " of the text-books careful 
examination of a patient about to display the external manifestations 
of systemic disease discloses the fact, as suggested above, that the symp- 
toms are by no means latent. The glands of many parts of the body 
beside those in the vicinity of the initial sclerosis become tumid and at 
times painful, including the tonsils and thyroid gland. The skin may 
exhibit icteroid symptoms as a result of hepatic disturbance ; the excre- 
tion of urea may be augmented or albumin may temporarily appear in 
the urine ; pains in the head, limbs, and other parts of the body may 
produce distress even of a severe grade ; the leucocytes may relatively 
increase in number ; the joints may become painful and swollen ; and 
muscular contracture with many other evidences of a morbid state of 
the system may indicate to the careful observer that a general process 
of intoxication is in more or less rapid evolution. 

At this moment, the " second incubative period " of the disease being 
completed, the patient is ready for an "explosion " of general syphilis. 
Insidiously or suddenly, first noticed upon the skin beneath the cloth- 
ing, with rapid efflorescence over the entire body-surface after a hot 
bath, the stimulus of liquor, or the excitement of the dance, appear 
the syphilodermata or syphilides or skin-symptoms of syphilis. 

Syphilodermata (Syphilides). 

The skin-manifestations of syphilis are of common occurrence, are 
numerous as to their forms, and are of the greatest importance from a 
diagnostic point of view. 

As in syphilis of other organs, that of the skin is betrayed in symp- 
toms like and unlike those of non-syphilitic affections. The study of 
these differences is here also a study of the syphilitic mode of disease. 
In a treatise of this scope and these limitations it will be practicable 
to describe merely those evidences of the syphilitic process to be recog- 
nized in the integument. 

Lesions of the skin appear in syphilitic individuals of both sexes, in 
all periods of life, and in all stages of the disease. These symptoms 
are, however, much more frequent during the first two years after infec- 
tion, subsequent to which period the manifestations of the disease are 
betrayed more commonly in subcutaneous lesions, or lesions which 



SYPHTLTS. 699 

affect the viscera, and the osseous, nervous, muscular, and vascular 
systems. 

General Characteristics of the Syphilodermata. — The syphiloder- 
mata, like chancres, are, properly speaking, modalities of such symptoms 
as occur in diseases not syphilitic. The distinctive difference between 
the papules, ulcers, and other lesions of syphilis and those of lupus, 
for example, lies chiefly in the mode of evolution and involution. It 
is the syphilitic behavior, rather than the syphilitic lesion, which guides 
the diagnostician. The syphilides, in short, resemble the lesions of 
most of the other diseases of the skin, and they differ also in various 
degrees from each one of the latter. Hence is seen the importance of 
a clear recognition of their general characteristics. 

Distribution. — The earlier skin-symptoms of syphilis are usually 
symmetrical, those occurring at a later period of the disease asymmet- 
rical, though in some cases there are exceptions of importance to the 
rule. Predominant sites of syphilodermata are the hairy scalp, espe- 
cially at its borders, the vicinity of the mucous outlets (angles of the 
lips and lids, anal and genital regions), the palms and soles, the alse 
and root of the nose and forehead, the interdigital spaces of the feet, 
the umbilicus, and the axillae and groins. The eruptive phenomena of 
syphilis may be general or few, and either conspicuous and formidable 
both as to their extent and persistence, or, instead, short-lived and 
insignificant. As a rule, the more general and profuse the earlier rashes 
of syphilis, the more favorable the issue with respect to the prognosis. 
Absence of Subjective Sensations. — The eruptions produced by 
syphilis are rarely attended by itching, burning, or painful sensations of 
any sort. This absence is frequently a positive aid in establishing a 
diagnosis, and, as a rule, is the more valuable the graver the lesion. 
Great difference, however, will be noted in this respect between differ- 
ent individuals. Occasionally considerable itching will be induced, 
as in condylomata of the anus ; and syphilitic ulcers, especially of the 
leg, may be productive of severe pain. At the same time it is a com- 
mon experience to find a patient quite tranquil as regards all subjective 
symptoms, covered from head to foot with a brilliant macular syphilo- 
derm, or exhibiting with the utmost composure a large number of 
serpiginous ulcerations on his scalp and extremities. 

Polymorphism, a term used to designate the coincident appearance 
of lesions of various character upon one individual, is as true of 
syphilis as of other diseases, such as lepra and scabies. Viewing the 
cutaneous and other symptoms of syphilis as a whole, this feature is 
strikingly significant, as it is possible to observe at one and the same 
time, upon the body of a single infected individual symptoms indic- 
ative of pathological changes in the skin, mucous membranes, hair, 
nails, lymphatic glands, and periosteum. 

To a less marked degree is this true of the syphilodermata. The 
type of syphilitic skin-lesions is generally papular, and such lesions 
may originate from macules, enlarge into tubercles, or degenerate into 
ulcers. The simultaneous coexistence of several of these forms is due 
to their chronicity, to their tendency to recurrence, and to the changes 
which they undergo. 



700 NEW-GROWTHS. 

Career. — The historical course of the syphilides suggests certain 
common features. They are rarely accompanied by local inflammation, 
and, with the exception of syphilitic fever, are usually unattended with 
pyrexia or with malaise. The tolerance by the general economy of an 
extensively developed syphiloderm is highly significant of specific in- 
fection. Again, though generally described as a chronic disease, syphilis 
is, judged with respect merely to time, much more acute than several 
other maladies. The syphilides have a distinct career, pursuing, even 
when untreated, a natural process of evolution and involution, and 
few, save those upon the lower extremities where the force of gravity 
is an important element in the fixation of all local disease, persist in 
unvarying type for any lengthened period of time. One lesion often 
succeeds another by development or by degeneration ; and many of 
the untreated syphilides disappear without leaving relics of their exist- 
ence upon the surface of the skin. In these last-named particulars 
syphilitic cutaneous manifestations are singularly different from those 
of lupus and of carcinoma, for example, where the lesion is usually of 
one type, and persists in one location for a period of time during which 
a syphilide would have progressed either to much more extensive 
damage or to permanent repair. 

Color. — There is no color peculiar to the syphilodermata that may 
not be seen in other diseases of the skin. It is important to recognize 
this fact clearly, as there are those who claim to diagnosticate the 
syphilides by their hue alone. The color, however, considered in 
connection with the other features of the syphilides, is highly char- 
acteristic, and often is sufficient to enable one at a glance to identify 
the disease. These color-shades are usually less brilliant than those 
seen in other dermatoses, and they possess less of the scarlet and pink 
quality. They are admixtures of red, yellow, and brown in various 
proportions, frequently with a slight preponderance of the brown. 
They have been compared with the color of raw ham and with that 
of copper, hues which unfortunately have been so associated with the 
syphilides that the no n -recognition of such tints has led to many 
errors in diagnosis. Pigmentation in various shades of chocolate, 
coffee, and black is recognized, both during the evolution and after 
completion of involution of the syphilodermata. In cases in which 
there has been no luetic affection the color, as in syphilis, is due to 
increase of pigment in the part, both with and without extravasation 
of blood. Recent syphilitic scars are usually pigmented both in centre 
and at the periphery. In these, again, it is not so much the color as it 
is the scar with the color that gives special significance to such lesion- 
relics. 

Contour. — In syphilis the contour of single elementary cutaneous 
lesions, as also of a group of aggregated lesions, is usually circular, or 
there is a distinct tendency to assume such a configuration. Thus, it 
is common to find outlines of patches, ulcers, and scars observing the 
curve of a segment of a circle, and the coalescence of several such 
lesions tends to produce the serpiginous aspect. Figures resembling 
a horseshoe, a kidney, a half-moon, the letter S, and a dumb-bell are 
thus produced. The earlier exanthems of syphilis are usually sym- 



SYPHILIS. 



701 



metrical, the latter asymmetrical. Even symmetrically distributed 
eruptions will at times"occur in annular patches, made up of maculo- 
papular lesions arranged in a circular or a crescentic line. Patches of 
syphilitic eruption will often clear at the centre and develop or spread 
at the circumference of a circle. 

Site. — No portion of the skin is free from the possibility of invasion 
by syphilis. The disease may involve at once almost the entire integu- 
ment ; or it may rapidly spread from point to point, having covered 
finally a large area ; or it may appear conspicuously at distant and iso- 
lated points of limited extent ; or, finally, it may be manifested exclu- 
sively in an insignificant lesion or a group of lesions, ephemeral in 



Fig. 75. 




Facial cicatrices of tubercular syphilodermata after twenty-five years of infection. 

course and limited to one portion of the body. The site of a syphilitic 
eruption may be determined apparently by the capriciousness of the 
disease, and yet result from local irritation of the skin of infected 
individuals. The accumulations on the napkins of women invite the 
occurrence of labial condylomata ; the lips of the infant, after contact 
with the nipple of the mother, become the seat of rhagades and fissures ; 
while the tongue of the tobacco-chewer and the fauces of the tobacco- 
smoker acknowledge special sources of mischief. 

There are some sites of preference for special lesions, as, for example, 
the squamous syphiloderm of the palms and soles ; and the papules of 
the forehead, constituting the so-called " corona veneris." 

Amenability to Treatment. — Mercury possesses a singular influ- 



702 NEW-GROWTHS. 

ence upon the syphilodermata that is perceived promptly when the drug 
is administered internally. This singularity rests upon the broad fact 
that the lesions of many other cutaneous diseases not only refuse to ac- 
knowledge the benefit of such medication, but in many cases are even 
aggravated by it. The importance of clearly recognizing the character 
of each cutaneous disorder submitted to treatment is thus well illus- 
trated. 

Character of Special Lesions. — Certain families of symptoms 
in syphilis exhibit characteristic features. Thus, some papular lesions 
are surrounded at the base by a peculiar fraying of the epidermis, in con- 
sequence of which they are encircled by a little fringe of scales resem- 
bling in shape a collar. The scales of syphilis are usually not abun- 
dant, but are fine, dirty whitish or occasionally brownish in color. The 
crusts of syphilis are apt to be bulky, greenish black in hue, and to 
surmount secreting ulcers of various depths. Such ulcers are gener- 
ally circular, or they exhibit in contour a tendency to assume the cir- 
cular line, while the cicatrices by which they are succeeded have a sim- 
ilar configuration. The scars of syphilis are frequently smooth, delicate, 
very slightly depressed, unattached to subjacent tissues, and pigmented. 
Lastly, from several of the secreting lesions of syphilis, especially those 
upon and about the anogenital region, proceeds a discharge having an 
offensive odor and capable of communicating the disease to a sound in- 
dividual. 

Subjection to External Agents Capable of Exerting an 
Influence upon Non-syphilitic Eruptions. — It is an obvious 
error to conclude that the exanthemata of syphilis are produced exclu- 
sively by the operation of a systemic intoxication. Many of the pustu- 
lar syphilodermata are the result solely of pyogenic cocci, and the 
extension of the eruption may be by inoculation and auto-inoculation. 
This fact is shown not merely by the ordinary methods of demonstra- 
tion, but also by the clinical fact that these lesions are far more frequently 
encountered among the filthy, the neglected, and the ignorant. Often 
syphilodermata are commingled with seborrheic and eczematous affec- 
tions. It is not rare to find patients applying for relief in clinical 
practice who exhibit lesions of syphilis commingled with traces of the 
incursions of lice and bugs, urticarial wheals, scratch-marks, and forms 
of keratosis pilaris, due to the unwashed condition of the skin. 

Syphiloderma Maculosum. — The cutaneous lesions of syphilis, limited 
to color-changes in more or less circumscribed areas of the skin, are 
exhibited in two distinct forms, due respectively to anomalies in blood- 
supply and pigment-distribution. 

Syphiloderma Maculosum due to Hyperemia (Erythem- 
atous Syphilide, Macular Syphilide, Syphilitic Eoseola). — 
This form of macular syphiloderm is the earliest expression of systemic 
cutaneous syphilis, and is more or less constant of occurrence, differing 
in this respect from several of the other syphilides. Often it is un- 
noticed by the patient, whose attention may first be called to it after 
its recognition by the skilled eye of another. It occurs in coffee-bean 
to filbert-sized macules, roundish, oval-shaped, or of irregular contour, 



SYPHILIS. 703 

and varying in color from a light rosy to a dull mulberry hue. In 
some cases these markings of the skin-surface are very indistinct, re- 
quiring for their recognition close scrutiny in a clear light, and occa- 
sionally even then leaving uncertainty in the mind of the expert. 
With a lens tinted in cobalt-bine they may be recognized at an earlier 
date than if viewed with the unaided eye. At times they constitute an 
irregular " marbling " of the surface, of a kind which renders it diffi- 
cult to define with the eye the individual lesions composing the erup- 
tion, while the general visual effect of the exanthem is distinct. The 
spots are not elevated above the general level of the integument, but 
may change in type, a papular lesion developing later in the same site. 

Like all macules of the skin due to vascular changes, those of 
syphilis vary in color with the complexion of the individual, with the 
time which elapses after their first appearance, and with vascular 
changes in the superficial plexus of blood-vessels. Thus, the deeper 
shades are usually observed in thick and muddy-tinted skins ; the more 
delicate tints upon the breast, for example, of blonde women. 

The eruption usually appears between the sixth and the eighth week 
after the appearance of the initial sclerosis, and, when untreated, de- 
velops for about one week more. It may be gradual or sudden in 
evolution and persists for a variable period of time, depending upon 
the severity of the constitutional disorder and the treatment to which 
the patient is subjected. During the early part of its career the hue 
of the lesions is lighter, and they may be made to disappear under 
pressure of the finger ; later, they are stained more deeply, and, exu- 
dation having occurred, the color of the spot does not disappear under 
pressure. When involution is in progress there is a slow disappear- 
ance of the eruption, which gradually fades from view. The vascular 
changes in the capillaries occasioned by cold, heat, and rapid cardiac 
contractions influence the eruption to a marked degree. A hot bath, 
a dance, a glass of spirits, a fit of excessive coughing, laughter, etc., 
may all bring the lesions into prominence. 

When the eruptive phenomena have been developed fully for two 
weeks or more, it is rather the rule than the exception to discover here 
and there over the skin-surface large-sized maculo-papules springing 
from the pure macular lesions, or sparsely distributed between the 
latter. 

The eruption may be limited to the skin of the belly, extending 
sparsely over the chest, the loins, the anogenital regions, and the 
thighs ; may develop over the palms, soles, forearms, and legs ; or, in 
exceptional cases, may profusely cover the entire surface of the body 
(face, ears, dorsal surfaces of the hands and feet, and skin of the penis 
with the progenital region). In the milder forms it is evidentlv sus- 
ceptible to external irritation of the skin, as it is common at the wrists 
where a starched cuff is worn, over the brow in the line in contact with 
the hatband, and is particularly well developed in men where the 
trousers are " reinforced " (perineum and inner faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is preceded 
by a febrile state, with marked amelioration of symptoms when the 
rash is fully developed ; while, again, it is throughout accompanied by 



704 NEW-GROWTHS. 

slight rise in the body-temperature, the patient having the so-called 
" bilious" appearance — muddy complexion, coated tongue, icteroid 
hue of conjunctivae, and offensive condition of the breath. Wander- 
ing pains in the extremities, and especially beneath the sternum, are 
frequently experienced. The last-mentioned symptom is highly sig- 
nificant, and the whole condition is probably due to the effect upon 
the nervous system of the circulation of the recently intoxicated blood. 
These pains are not those produced later in the periosteal and other 
complications of the disease, and are the more significant as the erup- 
tion itself is productive of a scarcely appreciable subjective sensation. 
The superficial ganglia of the body are usually engorged at the same 
time ; the fauces are congested ; the hairs of the scalp are slightly 
loosened in their follicles, and in the latter region in severe cases 
papules and pustules may form. Inasmuch as the order of sequence of 
most of the phenomena in syphilis is subject to a singular inversion, it 
occasionally happens that there is concomitance of later signs of the 
disease, such as iritis, affection of the nails and bones, or even, in special 
regions, of pustular, papular, or squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This point is of considerable importance. The 
physician should never conclude the examination of a patient com- 
plaining of suspicious genital lesions without carefully exploring the 
surface of the trunk, and also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where 
an initial sclerosis may exist. In a diagnostic and therapeutic sense 
the information thus gained may be precious, and in a large proportion 
of all cases is of a kind hidden from the knowledge of the patient. 

Relapses occur in certain cases with limitation of the disease to parts 
previously affected or unaffected. At the end of the first twelve 
months recrudescence of larger macules in annular groups may occur. 
Exceptional forms are noted in which darker puncta appear in the 
macular lesion, occasionally traversed by a hair. These puncta are 
localizations of a more intensely hypersemic or exudative condition 
about the orifices of the ducts of the follicles. 

The diagnosis of this syphiloderm is readily established in view of 
its essentially symptomatic character. From scarlatina, measles, and 
rotheln it differs in the indolence of the rash, the absence of decided 
elevation of body-temperature, and the order of its appearance in dif- 
ferent portions of the body, as it rarely occurs first upon the face. Ur- 
ticaria and the rashes induced by the ingestion of copaiba and other 
medicaments are distinguished by the marked itching of the affected 
surface and by their very general diffusion over the entire body, a con- 
dition rarely observed in the syphiloderm. Tinea versicolor, usually 
limited to the anterior surface of the trunk, is characterized by a fawn- 
colored to a chocolate-colored tint, by the furfuraceous desquamation 
which the patient usually describes as most noticeable after a hot bath, 
and by the existence of the readily recognized vegetable parasites upon 
the scales scraped from the affected surface. Tinea versicolor is, more- 
over, of much longer duration than a syphiloderm, and almost never 
extends to the exposed parts of the body — the face and the hands. 



SYPHILIS. 705 

Eingworm of the skin of the body is not symmetrical, and is a para- 
sitic disease. 

All these distinctions, however, are not to be compared in diagnostic 
value with the concomitant symptoms of syphilis that are very generally 
present, such as adenopathy, persistence of the initial sclerosis, and 
evident involvement of other than cutaneous tissues. Such concom- 
itant symptoms will be found occasionally with a non-syphilitic erup- 
tion due to drugs ingested for relief of the infectious disease. The 
most common of these drugs is potassium iodide ; the eruptions it pro- 
duces are frequently found both commingled with the macular syphilo- 
derm and occurring on the eve of the appearance of the latter. The 
existence of acneiform lesions upon the face, the neck, and the posterior 
surface of the trunk, a vivid erythema of the forearms, including the 
hands, and purpura-like maculations of the face, legs, and feet, should 
never mislead the physician as to the character of the disorder with 
which he is confronted. It is undeveloped syphilis with a dermatitis 
medicamentosa of the surface. Suspension of the iodide, which drug 
fortunately is not required in the majority of cases ; the use of a properly 
selected mercurial, or even (and this is often wise)' abstention from all 
medication, will be succeeded by disappearance of the cutaneous lesions, 
which may be followed later by a mild macular syphiloderm, altogether 
insignificant in comparison with the eruption artificially induced. 

Syphiloderma Maculosum due to Anomalous Distribution 
of Pigment (Pigmentary Syphilid e, Vitiligo Acquisita 
Syphilitica, Leucoderma Syphiliticum). — The eruption, if it 
jnay be so called, is relatively rare, and characterized by the appear- 
ance upon the body-surface of irregularly circular, usually poorly 
defined, dirty brown and chocolate-tinted macules, which, as they are 
unconnected with vascular changes, do not disappear under pressure. 
The lesions occur as sparse, well-isolated discolorations, or, more com- 
monly after a species of confluence, as an irregular rete or network, 
with relatively large interspaces characterized by an absence of color- 
ation. The eruption is most common upon the sides of the neck, the 
shoulders, and breasts, though it may involve more rarely the surface 
of the trunk and the extremities. It is most frequent during the first 
year after infection, though it may develop later. 

It occurs (a) as a sequel to a macular or maculo-papular syphiloderm 
over the parts described above ; and (b) ab mngine, as a pigment-dis- 
order, probably under the same influences as those productive of the 
chloasmata of symptomatic origin (chloasma uterinum, cachecticorum, 
etc.). In our experience this last is the more usual origin of the dis- 
order. 

This manifestation of syphilis in the skin belongs to a group of 
phenomena- with respect to which there is doubt whether it be a direct 
product of the syphilitic virus or rather an achromia due to the causes 
efficient in other pigment anomalies of the skin made operative by the 
underlying syphilitic dyscrasia, under the influence of which alone it 
develops. There is good reason for the belief that the latter of the 
two explanations is to be accepted, Fournier, for example, 1 placing 
1 Les Affections Parasyphilitiques, Paris, 1894, p. 12. 
45 



706 NEW-GROWTHS. 

this among the group of " parasyphilitic affections " described by him, 
the others in the same class being for the most part disorders of the 
nervous system. One of the chief reasons cited by Fournier for this 
association is the well-known fact that the pigmentary syphiloderm is 
singularly insusceptible to the action of antisyphilitic treatment, and 
this although the symptoms are declared usually during that stage of 
syphilis in which the eruptive phenomena are commonly symmetrical 
of development and particularly amenable to an appropriate therapy — 
that is, during the first two years after infection. The pigmentary 
syphiloderm is usually unproductive of subjective sensations, is more 
conspicuous in the skin of blonde women but more common in bru- 
nettes, and, in our experience, more frequently visible on the skins 
of mulattoes, Mongolians, and Indians than among persons of Aryan 
descent. Though more often affecting women, it can be recognized in 
typical development in adults of the male sex. 

The color-changes observed in the skin are explained by the occur- 
rence : first, of pigmentary deposits, possibly at the centre of the ordi- 
nary macular or papular syphiloderm ; second, of peripheral absorp- 
tion of such pigment-deposit, with possible persistence of it for a 
variable time at the centre of the lesion ; third, of total absorption 
of all pigment from the original lesion ; and lastly, of peripheral 
hyperpigmentation of the spaces intermediate between the original 
macules. 

The eruption is an epiphenomenon of the syphilitic process, being 
rarely amenable to the treatment under which other macular syphilo- 
dermata speedily disappear, and is an expression rather of general 
deterioration of the health of the skin than of specific disease. A 
chief reason for regarding its origin as wholly distinct from the pre- 
cedence of a syphilitic exanthem is found in the fact that while the pig- 
mentary stains, which are relics of syphilodermata, almost invariably 
disappear by resorption in the course of two years when of occurrence 
in the upper segment of the body, the pigmentary syphiloderm has 
been recognized by us as among the stigmata of lues ten years and 
more after infection. 

The eruption is liable to be mistaken for that condition in which 
there is simply an accumulation, upon a somewhat greasy skin, of 
secretions and dust, to be seen upon an integument long unwashed. 
Tinea versicolor has a more yellowish or fawn-colored tint, and, as a 
rule, is developed more abundantly upon the front of the chest than 
upon the neck. Neither vitiligo nor leucoderma is disposed sym- 
metrically, as is usually the case with the pigmentary macular 
syphiloderm. 

Syphiloderma Papulosum. — The type of all cutaneous lesions pro- 
duced by syphilis is to be recognized in the papule. Most of the 
other lesions are either developed from it, transformed to it, or by 
reversion or admixture confess that the neoplasm of syphilis in the 
skin is essentially a more or less solid circumscribed cutaneous lesion, 
varying as to size and history. 

Papules occurring in syphilis may appear as the first cutaneous 



SYPHILIS. 707 

evidence of infection, or they may be developed from earlier macules. 
They may be small, large, acuminate, flat, disseminated, or in groups. 

Small Acuminate Miliary Papular Syphiloderm (Syphi- 
litic Lichen). — In this eruption the lesions are millet-seed to hemp- 
seed-sized, circumscribed, globular, acuminate, reddish and salmon- 
reddish, firm elevations of the surface, or minute nodules upon the 
skin, generally symmetrically developed, often over the entire body, 
closely set, and occasionally grouped in crescentic figures. When 
viewed with care a minute vesicle, a pustule, or a scale may often 
be detected at the conical apex of each papule, the vesicular or pus- 
tular lesions rarely developing to such an extent as to become a 
characteristic feature of the eruption. The color is, at first, especially 
in blonde skins, a species of salmon and red. mixed; later, the darker 
and browner shades appear. When generalized, the eruption is well 
developed, especially over the posterior surface of the body, the occipito- 
cervical and scapular regions, the buttocks, and the calves of the legs, 
though it is often distinct about the anus and the genitalia. Like 
several other of the syphilodermata, its earlier are more symmetrical 
than its later manifestations, whether these be tardy or relapsing, or 
both. Involution occurs by resorption of the plastic exudate, minute 
and usually scanty, dirty-whitish scales encircling the base of each 
lesion. When the eruption has proved especially persistent, marked 
pigmentation follows in the form of brownish-red blotches, the centre 
of each of which displays a cicatriform relic in the form of a punctum. 

The eruption often is noticed first about the forehead, nose, mouth, 
neck, and shoulders — localities commonly subject to topical irritation. 
Occasionally the posterior aspect of the trunk will be affected ex- 
tensively. On the face an exceedingly striking picture is presented 
when the papules are grouped in rather vividly tinted rings. About 
the forehead in men the papules will frequently be arranged along the 
surface pressed by the lining of the hat, and frequent fingering of the 
face, shaving, and irritation by the edge of the collar of the shirt may 
determine a more speedy efflorescence at the sites of contact. About 
the mouth tobacco plays the part of an excitant ; about the nose a 
localized seborrhoea may be added to the syphilitic phenomena, in 
which case the lesions may be covered with thin, greasy crusts. The 
eruption occurs during the first six months after infection, and is 
usually fully developed after a fortnight when no treatment has influ- 
enced its evolution. It is observed rarely in well-treated cases, and is 
encountered more often when there has been ignorance or no treatment 
of the disease. When the lesions are perforated by hairs they suggest, 
on superficial examination, a resemblance to keratosis pilaris, and when 
aggregated in patches of distinct contour they may be confounded with 
psoriasis or squamous eczema ; but in every case the general physiog- 
nomy of the disease may well be trusted for the establishment of a 
diagnosis, having in mind the color, the absence of intense pruritus and 
serous exudation, the disposition over the body as ^ whole or in por- 
tions widely separated, and the rarely failing concomitant evidence of 
syphilitic infection. The eruption as a whole is indolent both in 
evolution and involution, at times persisting for weeks, though it is 
quite amenable to vigorous treatment. 



708 NEW-GROWTHS. 

Large Acuminate Papular Syphiloderm. — Lesions of the 
character above described occasionally develop to an unusual extent, 
attaining the size of that of a coffee-bean in localities where the apex 
of each lesion is free to push forward without coming into contact with 
adjacent planes of the integument. Thus, about the dorsum of the 
body, the gluteal regions, the calves of the legs, and the extensor sur- 
faces of the forearms, fully developed, slightly scale-capped or scale- 
encircled, and grouped papules may appear, often commingled with 
pustules and superficial ulcers, the polymorphic patch having a figure- 
of-eight or S-shaped outline. These patches are often displayed by 
patients under treatment the influence of which has interfered with the 
full evolution of the disease. 

Small Flat Papular Syphiloderm. — The lesions recognized 
under this title differ from those just described in that they are not 
acuminate, but are distinctly flattened at the apex, this flattening being 
at times so pronounced that each lesion resembles a small button or a 
plaque, the contour being roundish or oval-shaped. The lesions are 
frequently encountered on the face, especially near the mucous outlets, 
over the anterior and posterior surfaces of the trunk, and on the flexor 
aspects of the extremities. The palms of the hands are often affected. 
In color the papules exhibit the variation usual in individuals of dif- 
ferent complexions, and in the same individual as they are related to 
the condition of the circulation. Thus, on the face a scarcely distin- 
guishable pink will become a deep, lurid, reddish brown from an attack 
of sneezing, a paroxysm of laughter or of rage, and from violent exer- 
cise. The seborrheic condition noted on the face in the acuminate 
lesions is also occasionally seen about the plaques. The same is true 
of the scaling described above. The eruption is much less copious, as a 
rule, than with other forms of syphilitic papules, due doubtless to the 
fact of its subjection to treatment. The papule differs from the lesion 
about to be described with respect to its size, being rarely larger than 
a small button ; while the largest papules of the same variety may 
attain the size of large coins. The diagnosis has already been suggested. 

Large Flat Papular Syphiloderm. — Here the resemblance of 
the papule to a button is even more distinct, the lesion occurring with 
a well-defined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of each plaque is a smooth, flat plane. The large papules commonly 
begin as macular lesions and rapidly develop at the periphery, this 
development often corresponding with centric involution, by which the 
shallow depression described above is reduced to the level of the adja- 
cent skin and the lesion is transformed into a ring. In shape the 
papules are circular and oval; in size they vary from that of a finger- 
nail to that of a pigeon's egg. They have the usual variation in color, 
and may scale at the edge, or over the flat top or the depressed centre. 
In moist situations they frequently secrete a muco-purulent fluid which 
is smeared over the papules and adjacent integument, and which, in the 
vicinity of the anus or genitals, exhales an offensive odor. It is especially 
in such situations that flat papules of the type described occasionally 
degenerate by fissure or by circular ulceration. Condylomata Lata 



PLATE XXIV, 




Annular Papular Syphiloderm. 



SYPHILIS. 



709 



are flat and secreting papules of the regions named, which have a whit- 
ish appearance in consequence of the mucoid secretion with which they 
are smeared, and which are transformed by the influence of heat, moist- 
ure, and either friction or apposition of contiguous integumentary folds. 

Papular syphilodermata may become generalized or be limited to 
certain sites of preference, as the face, the neck, the flexor surfaces of 
the extremities, and the anogenital region. The eruption is either an 
early, a late, or an intermediate symptom of syphilis, occurring most 
abundantly in young and delicate skins, where the disease has been 
ignored and therefore untreated; and most scantily in the thicker 
integument peculiar to middle life, w T here prompt resort has been had 
to appropriate medication. 

Syphilitic papules undergo a series of modifications under the influ- 
ence of various causes which may be enumerated as follows : 

(a) There is considerable hyperplasia of the cutaneous elements 
(papillary layer of the corium, rete, and blood-vessels), by which the 
papule becomes largely raised from the surface, so as to resemble a 
papilloma, wart, or the lesions characteristic of frambcesia. In this 



Fig. 76. 








Jw" ^ *1 




1?-^B 




yfli 






■■^Hl 



Vegetating condylomata of the anus. 

way, rarely, a portion or the entire surface of the" body may be cov- 
ered with light-red or violaceous-red, non-ulcerative, vegetating growths. 
They secrete freely, and the discharge is liable to concrete into crusts 
and to exhale an offensive odor. 

(6) There is considerable hyperplasia of the elements, in conse- 
quence of which the lesions spread laterally, while their elevation from 
the surface is prevented by contact with apposed surfaces. Thus is 



710 NEW-GROWTHS. 

formed the broad, flat, moist papule known as the " vegetating mucous 
patch," " condyloma," plaque muqueuse, etc. (Fig. 76). The lesions, 
when unaltered and fully developed, are of a whitish color in conse- 
quence of the puriform mucus which covers them, and which, as with 
so many of the syphilodermata in moist situations, is liable to exhale 
an offensive odor. When the secretion is removed the lesion is seen 
to be pinkish, or light or dark red in color, and to be either firm or 
soft, scarcely raised, and indefinite in contour, or distinctly elevated 
and well defined. Condylomata are chiefly found in moist situations 
where folds of the skin are apposed, as about the perineum, the groins, 
the axillse, the mammae, the nates, the anus, the genitals, and the inner 
faces of the thighs. They may coalesce to form palm-sized patches ; 
and the dried products of secretion from the adjacent mucous outlets. 
They are often the source of a considerable pruritus. 

(c) In consequence of changes in the superficial layers of the epi- 
dermis the papules may become covered with scales, either at the base 
or the apex, more commonly the latter, forming thus the papulo-squa- 
mous syphiloderm. The scales are of a dirty-grayish hue, often des- 
iccated, generally attached, rarely freely exfoliating. They are rela- 
tively few, occurring where the lesions are closely set. The desqua- 
mation may be the most suggestive feature of the patch. Beneath 
the scales are seen distinctly elevated brownish-red papules or merely 
slightly elevated, dull-red or purplish-red maculations. When the 
scales accumulate at the base of the papule they tend to surround, it 
with a circlet or collarette of exfoliated shreds of epidermis. 

Palmar and Plantar Syphilides. — In -consequence of the thick- 
ness of the epidermis in the palms and soles the papular or papulo- 
squamous syphiloderm of these regions is presented under somewhat 
atypical forms. The dense stratum corneum of the epidermis in the 
palms and soles is not readily raised from its underlying tissue into 
papular forms. The pathological manifestations of this disease are 
rather displayed in thickenings, separations, stainings, and frayings. 

Here, therefore, are seen dull-red maculations, covered throughout, 
or merely at the edges, by scales or epidermal shreds ; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the blood-vessels beneath the opaque horny layer ; and 
distinctly elevated (not flattened) and circumscribed papules, or papulo- 
tubercles of the usual livid-red color, coffee-bean- to small-nut-sized, 
often aggregated in patches having a tendency to assume the circinate 
outline. Occasionally with a pointed instrument pinhead-sized and 
larger deposits resembling chalk may be pried from circular beds in the 
palms and soles where the lesions first developed. These and similar 
spots often are covered with dirty-whitish, often tenacious, half-loosened, 
epidermic flakes which are characteristic. In other cases, usually in 
consequence of the motions of the hand or the foot, or the exigencies of 
toil, irregular angular losses of epidermis occur resembling the fracture 
of a pane of glass. The attached portions of the epidermis project 
at the edges only, over deep fissures, broad exulcerations, or a ham-red, 
tender, and newly formed epidermic stratum. 



SYPHILIS. 



711 



The eruption is frequently symmetrical in the centre of both the 
palms and the soles, but is rarely found upon the dorsum of the hands and 
the feet, and then never developed typically, but always by extension 
from the palmar or plantar regions ; it is also seen on the lateral sur- 
faces of the hands, feet, fingers, and toes, as well as over the wrists 
and ankles. The exanthem is a persistent, rebellious, and usually 
late cutaneous symptom of syphilis, occurring often six, eight, and 
more years after infection. Rarely it is seen within a few months after 
the existence of chancre, and is then usually manifested in its simpler 
forms. 

Fig. 77. 




Corymbose papular syphilide. 



The papulo-squamous syphiloderm bears in many instances a strong 
resemblance to the patches of psoriasis, but it can usually readily be 
distinguished from the latter by a consideration of the following points : 

The syphilide, as a rule, is not generally diffused ; it displays sym- 
metry only when it involves the palms and soles, and then not invari- 
ably ; it is elevated at the border of the patch ; and it observes the 
contour of the segment of a circle. Psoriasis is more widely dif- 
fused ; is generally symmetrical ; does not specially exhibit elevation 
at the border of the patches, and the latter are rather more completely 



712 NEW-GROWTHS. 

than partially circular in outline. In syphilis there is generally a his- 
tory of infection, of other cutaneous or mucous symptoms of the dis- 
ease, and, in married women, of abortions, miscarriages, or births of 
diseased children, all of which symptoms are wanting in psoriasis. In 
psoriasis there is a decided predisposition to the development of the 
disease about the extensor surfaces of the joints and the posterior 
aspect of the trunk ; the syphiloderm, though it may occupy these 
situations, can rarely be found thus displayed when other surfaces are 
spared. The scales in psoriasis are more lustrous, are more freely pro- 
duced and shed, and they exist significantly at an earlier period of the 
exanthem. With only such exceptions as prove the rule, psoriasis 
is never strictly limited to the regions of the palms and soles. A 
scaling palmar or plantar disease of the skin in childhood is more 
likely to be psoriasic, though both diseases are seen in the early periods 
of puberty. 

Eczema is recognized yet more readily by its production of itching 
in varying grades, its history of discharge and moisture, and its char- 
acteristic crusts. Ancient patches of squamous eczema are often very 
indeterminate in outline ; they do not ulcerate, and they exhibit scales 
on the surface of a much more deeply infiltrated area. Eczema of the 
palms and soles, when chronic, usually involves also the dorsum of the 
hands and the feet. When this is not the case the eczematous infiltra- 
tion, if of long duration, will in the vast majority of all cases be found 
to involve uniformly and evenly the entire palm or sole, including the 
palmar or the plantar faces of the digits. Eczema, finally, is encoun- 
tered much more frequently solely upon the right hand in right-handed 
patients, or to a greater extent in that organ by reason of its preference 
in the performance of function. This is less common in syphilis. 

Syphiloderma Vesiculosum (Varicellaform Syphilide). —Vesicular 
syphilodermata are rare cutaneous symptoms of syphilis if they do 
actually occur. Pinhead- to pea-sized, conical, globoid or umbili- 
cated, isolated or grouped, and crusting elevations of the epidermis, 
with lucid or cloudy contents, have been observed upon the face, 
the trunk, and the genitalia of syphilitic subjects. The eruption is de- 
scribed as an early syphiloderm, often exhibiting a halo of charac- 
teristic tint, the resulting crusts being granular and somewhat lighter 
in color than those commonly seen in the disease. Both small and 
large vesicles have thus been assigned to the disease, and these, accord- 
ing to their resemblance to non-specific exanthemata, have been de- 
scribed as varicelloid, herpetic, etc., terms of indefinite characterization. 

But the larger number of the lesions are, without question, either 
immature pustules, eczematous lesions in syphilitic subjects, or pure 
accidents of the syphilitic process. With regard to the first, it may 
be said that the pustular syphiloderm not rarely begins as a vesicular 
lesion ; with regard to the second, that coincidence of so common a 
disease as syphilis with other cutaneous disorders is a matter of fre- 
quent observation ; and with regard to the third, bearing in mind the 
large quantity of potassium iodide swallowed for the relief of the dis- 
ease and its capability of exciting a vesicular eruption, it can reasonably 



SYPHILIS. 713 

be concluded that some, at least, of the cases of so-called " vesicular 
syphilis " have been studied imperfectly. 

Syphiloderma Pustulosum. — In some of the pustular syphilodermata 
the pus is neutral ; in others the staphylococcus pyogenes aureus and 
albus are present. The larger number of all pustular affections of the 
skin, whether in syphilitic or in non-syphilitic subjects, are the results 
of infection with pus-cocci. It is therefore not sufficient in syphilis to 
pronounce upon the question of infection only. It is necessary further 
to explain many of the external phenomena of the disease by the acci- 
dents to which non-syphilitic patients are subject. 

These accidents are probably of more frequent occurrence in pus- 
tular syphilodermata than in any other lesions exhibited in the disease. 
Viewed as a whole, it is noticeable that pustules occur for the most 
part in dispensary and hospital practice, among the impoverished, the 
filthy, the ill-housed, and the poorly treated. They are decidedly rare 
in the clientele of the physician consulted chiefly by those who are 
cleanly, well-nourished, and skilfully treated. If it were possible to 
keep the skin of the syphilitic subject aseptic during the management 
of the disease, no one would expect an evolution of pustular syphilo- 
dermata at any time throughout its course. The lesions described 
under this title may therefore be regarded for the most part as due to 
the causes suggested above, aided by picking and scratching the skin 
to an extent capable of distributing staphylococci over its surface. In 
other cases it cannot be denied that pustules, general of evolution and 
characteristic in appearance, may develop in consequence of luetic 
infection only ; but even of this type they are rarely to be seen in the 
better class of patients. 

Pustular lesions in syphilis further present a wide range of dif- 
ferences. They may vary in size from that of a pinhead to that of a 
finger-nail ; they may be acuminate, flat, hemispherical, or irregular in 
shape ; they may be few or be very numerous ; they may be distinctly 
localized or be generally dispersed ; they may be grouped or be dis- 
seminated ; and they may occur from the first as minute vesico-pustules 
or as pustular transformations of variously sized papules. They may 
be surrounded by inflammatory areolae, or may spring from an unaltered 
integument, or be subepidermic in situation, and scarcely project from 
the surface. They may be seated upon superficial or deep, or sharply 
cut, secretory ulcers, and they are usually covered with crusts differing 
in bulk and consistency, forming thus the pustulo-crustaceous syphilide. 
According to the depth of the ulceration at the base are they followed 
by cicatrices. Pigmentation is a frequent result. The crusts which 
form by the desiccation of pus are usually reddish brown to greenish 
black in hue ; they occur in strata or laminae by accretions from beneath, 
and, even when superimposed upon a moist and secreting ulcer, they 
are adherent at the edges. They may occur early or late in the cjis- 
ease, and at either epoch may constitute trifling or grave cutaneous 
lesions. They have a marked predisposition for involvement of the 
sebaceous and pilary follicles, and they are frequently disposed about 
the mucous outlets of the body. 



714 NEW-GROWTHS. 

Small Acuminate Pustular Syphiloderm (Miliary Syph- 
ilide). — This exanthem, which usually is diffused over an exten- 
sive surface, probably represents, as Jullien has suggested/ a trans- 
formation from papular lesions, due to pus-infection of skins that 
are usually unclean, irritated, or the seat of diminished vitality. The 
eruption is certainly rare in patients of the better class. The pustules 
are recognized generally about the pilo-sebaceous orifices, and upon 
minute papular lesions, which, as undisguised elements of the eruption, 
may be interspersed among the latter. The pustules are acuminate 
and contain each but a droplet of cloudy serum or pus, the desiccation 
of which furnishes a thin yellowish or reddish-brown crust. The fall 
of the latter exposes the grayish epidermal fringe of the base occasion- 
ally seen in papules of similar size. They occasion little or no sub- 
jective distress save when they occur coincidently with syphilitic 
fever. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and the trunk are 
chiefly involved, though the disease may be well-nigh universal. 
Under the influence of treatment occur minute, punctiform, and pig- 
mented cicatricial atrophic depressions which are not persistent. The 
eruption may be an early or a late secondary symptom, but usually it 
is first seen within a few months after infection. Relapses occur when 
treatment has irregularly been pursued. Frequent concomitants are 
those symptoms of syphilis proper to the period in which they appear. 
Miliary papules often are interspersed among the pustules. The 
eruption, aside from uncleanly conditions, is seen chiefly in so-called 
" ignored " cases. 

Large Acuminate Pustular Syphiloderm (Acneiform, 
Varioliform Syphiloderm). — This exanthem of syphilis, sometimes 
generalized, occurring if at all within the first eight months after infec- 
tion, is eminently an expression of syphilis in the filthy skin. It is 
exceedingly rare among the better class of patients, and can often be 
explained by the wearing next the skin of coarse woollen, not often 
laundered, undergarments by laboring-men. 

The eruption consists of small or large pea-sized, grouped or dis- 
seminated, acuminate or well-rounded, fairly well-distended pustules, 
which may be seated at the orifices of the pilo-sebaceous ducts. The 
lesions may begin as pustules or papulo-pustules, and may have a tinted 
border of a coppery hue. The fact that sometimes the lesions suggest 
umbilication has led writers to use the term varioliform in their descrip- 
tion, an unfortunate term which tends to introduce confusion in the 
description of strictly syphilitic lesions. The eruption may be scanty or 
profuse, be rapid or slow in evolution ; may develop in crops, and may 
concur with syphilitic fever, as in the instance of the rasfr last de- 
scribed. When desiccating, the pustules furnish a dirty-brownish, 
occasionally blackish crust, covering ulcers of varying depths. The 
scars left may be persistent, but usually lose many of their distinctive 
features in the lapse of time. 

The eruption is, aside from the covered skins of the uncleanly, seen 
also on the face (about the alne of the nose and about the mouth) in the 



PLATE XXV. 




Large Pustulo-erustaeeous Syphiloderm of the Scalp and Body 



SYPHILIS. 715 

subjects of the disease who are cachectic, anaemic, or long given to 
excesses in drink and debauchery. 

The diagnosis between this eruption and variola is established 
readily in view of the rapid changes occurring in the last-named disease, 
the febrile phenomena, the order of appearance of the variolous ex- 
anthem, and the evidence furnished by other non-cutaneous symp- 
toms of syphilis which are usually present. The drug exanthemata 
usually are characterized by more pronounced subjective sensations ; 
the several forms of impetigo are seen very rarely elsewhere than on 
the face and hands ; and acne, limited chiefly to the face and shoulders, 
never furnishes a distinct ulcer beneath its crusts, and is accompanied 
by characteristic comedones and other stigmata, over the scalp and 
elsewhere, of a sebaceous gland disorder. The lesions may spring from 
macules or smaller pustules, very rarely from an indurated or a papular 
base. They have a thin roof-wall, occurring by preference where the 
epidermis is delicate, and they are surrounded by a halo. They are 
usually acuminate, but after full evolution they may flatten slightly at 
the apex in consequence of partial collapge. The crusts are bulkier 
and darker in color than those of the lesions just described ; their bases 
are ulcerated superficially. The pustules form slowly or rapidly, in 
disseminated or in grouped forms, usually at an early period of the 
disease, though commonly after the appearance of some syphilide of 
another type. 

Small Flat Pustular Syphiloderm (Impetigoform Syph- 
iloderm). — This is a relatively frequent manifestation of syphilis, 
occurring upon the face, the scalp, the trunk, and the flexor surface of 
the extremities, usually within the first year after infection. The 
exanthem exhibits a decided tendency to characteristic and circular 
grouping about the mucous outlets of the body. Such groups are com- 
posed of small, flat, discrete pustules, pinhead- to pea-sized, originating 
as reddish, macular lesions which tend to dry into flattish, irregular, 
dirty-yellowish or brownish, adherent crusts. These crusts either 
exceed the limits of the diseased surface beneath, or are conspicuous 
upon a dull brownish-red area of inflamed, eroded, and at times even 
of ulcerated aspect. 

Often the pustules are so closely set as to become confluent, in which 
case a single convex crust, like a carapace, will completely cover the 
involved area. Frequent sites of the exanthem are the regions about 
the nose and the lips, as also the chin, cheeks, and the anterior faces of 
the elbow- and wrist-joints. 

The eruption is of pustulo-crustaceous type, and it may be evolved 
from either papular or macular lesions. It is rarely long untreated, 
and is therefore not often presented for observation when in full evolu- 
tion. It is usually amenable to judicious treatment; when followed by 
severe ulceration, destroying an ala of the nose or a part of the lip, the 
patient has usually suffered from either cachexia or neglect. In these 
cases less severe phenomena are presented in the superficial serpiginous 
syphilide, the lesions extending in circinate or annular gyrations about 
a sound or a previously involved and healed centre. Thus, a circlet 
of crusts, with underspreading superficial ulceration, perhaps alternating 



716 NEW-GROWTHS. 

with pustules of various ages and reniform cicatrices, will surround the 
elbow or traverse the scalp. The resemblance to pustular eczema is at 
times suggestive, but the ulceration and outline as well as the absence 
of itching will aid in their recognition. The lesions are usually late 
among the earlier symptoms of the disease, but they may be delayed for 
six months after infection. They indicate, as a rule, either severity of 
the disease, or, much more commonly, constitutional impairment. 

Large Flat Pustular Syphiloderm (Echthymaform Syphi- 
loderm). — The lesions classed under this title are fully developed forms 
of those described above. They originate as usually numerous, maculo- 
papular lesions, or as nodules or tubercles which gradually deepen into 
pea-sized and even larger flat pustules, the further history of which is 
one of enlarging, blood-mixed, reddish- and greenish-brown, also flat- 
tish, crusts with underspreading pus-bathed ulceration of varying ex- 
tent. The superficial variety of this syphiloderm is distinguished from 
the deep chiefly by the extent of its ulcer, the size of its superimposed 
crust, and the lighter, dull-red areola which encircles it. 

Pustulo-ulcerative Syphiloderm. — The deep variety, like the 
superficial, may be limited to the scalp, face, neck, and flexor aspects 
of the extremities, or it may be diffused much more widely. The 
entire surface of the body may be covered with discrete lesions of 
this type in cases of unusual neglect or of profound cachexia. The 
eruption is usually of late occurrence, but in the so-called "galloping- 
syphilis" of the French it may be precocious in development. The 
lesions are at the onset nodular or tubercular and become trans- 
formed into pus. They have each a deep infiltrated base with a 
dark-brown halo. Incrustation follows with the formation of a coni- 
cal, roundish, or oval-shaped, blackish-brown crust, beneath w r hich 
lies a clean-cut ulcer, the sharp edges of which are usually exactly 
roofed by the incrustation. The crust thickens by concretions from 
the foul and purulent ulcer beneath, and spreads at the periphery while 
it thickens in the centre. In this w T ay the appearance of the stratified 
crust resembles that of an oyster-shell, a condition described by some 
authors as Rupia, a term once employed as the name of a disease. 
The ulcer, exposed after removal of the crust, is of characteristic 
syphilitic type in its deep base, foul floor, clean-cut edges, and puru- 
lent secretion commingled with blood, at times attaining a diameter of 
several inches, and having a circular, reniform, or horseshoe-shaped con- 
tour. The degree of destruction it may produce is inversely proportioned 
to the constitutional vigor of the subject and the treatment pursued. It 
is usually a grave and may be a malignant exanthem, though under 
favorable circumstances it is amenable to judicious treatment, and may 
be an early, though oftener it is a late symptom of the disease. The 
pigmented scars left are characteristic and indelible. 

Syphiloderma Bullosum (Pemphigus Syphiliticus, an unfortunate 
designation). — Bullae in acquired syphilis are late and relatively rare 
lesions. They are rarely numerous, pea- to large-nut-sized elevations 
of the epidermis, filled at first with a cloudy serum, which soon is 
transformed into pus, often mingled with blood. They have usually a 



PLATE XXVI. 




Tubercular Syphiloderm, Resolutive and Serpiginous. 



SYPHILIS. 717 

characteristic halo about the periphery ; are roundish or oval in contour ; 
are usually discrete, rarely disseminated ; and after development they 
produce characteristic crusts with underlying ulcers, identical in feat- 
ures with the rupioid sequels of large syphilitic pustules. The eruption 
is localized by preference upon the extremities, more particularly the 
lower extremities, and is indolent in its course. It is always significant 
of a cachectic condition in the subject of the disease. Its frequent 
occurrence in congenital syphilis is described later. It is to be distin- 
guished from pemphigus vulgaris by its characteristic crusts and ulcers, 
considered in connection with the history and associated symptoms of 
lues. 

Syphiloderma Tuberculosum. — In this eruption which may develop 
within the first year after infection, but which often is deferred much 
longer, the lesions are usually multiple, flat, roundish, circumscribed, 
firm, light-red to dull crimson-red nodules, beginning commonly as 
macules of a lurid hue. They vary in size from that of a coffee-bean to 
that of a small nut, and involve the entire thickness of the skin, often 
also the subcutaneous tissue. Their surfaces are smooth, glazed, or 
desquamating ; and their evolution is peculiar in that they rarely exhibit 
apical pustulation or ulcerative degeneration. 

The eruption is, with few exceptions, usually limited to one or more 
regions of the body, as the forehead, the chin, the nucha, the buttocks, 
and the outer surface of the thigrhs. It is less often disseminated than 
grouped. Occasionally there may be displayed upon the surface of the 
body but a single tubercular lesion, the recognition of its character 
usually demanding some skill on the part of the diagnostician. When 
occurring in groups the typical eircinate appearance of the syphilo- 
dermata in general may be wanting, the patches having an irregular 
boundary ; but at times the circular, reniform, or horseshoe-shaped out- 
line is distinct, with an enclosed area of integument unaltered or the 
seat of atrophic changes. In these cases there may be complete 
coalescence of lesions with flattening and necrosis or ulceration at one or 
several points. At times the lesions assume a serpiginous character 
and distribution, a condition to which has been applied the term 

Syphiloderma Tuberculosum Serpiginosum (Circinate Tubercular 
Syphiloderm). — In exceptional cases serpiginous and tubercular lesions 
are marked by secondary changes. They may become covered on the sur- 
face with a thin yellowish crust ; may lose their firmness and become 
soft and rather more lurid red in hue, from colloid, or rarely even sup- 
purative, degeneration ; may vegetate luxuriantly and become the seat, 
especially on the scalp, of warty growths, smeared with a semipurulent 
secretion of disgusting odor (syphilis papillomatosa, syphiloderma fram- 
boesioides) ; or finally they may ulcerate, the superimposed crusts 
thickening in bulk, deepening into blackish and greenish shades, and 
covering typical syphilitic ulcerations, with characteristic edges, floor, 
base, and secretion. The degeneration in the latter case may be rapid 
and the destruction extensive. This result is, however, of rare 
occurrence. 



r 



718 



NEW-GROWTHS. 



The course of the eruption is indolent, months usually elapsing 
before full evolution is accomplished. In untreated cases there is pro- 
duced a generalized and symmetrical syphiloderm. It is rare, how- 
ever, even in hospital and dispensary cases, to observe such develop- 
ment; the more superficial, generalized, and symmetrical are the 
lesions, the briefer, as a rule, is the interval between such an eruption 
and the date of infection. The later the lesions, the more are they 

Fig. 78. 




Ulcerative tubercular syphiloderm. 

asymmetrical, localized, and profound in their involvement of the deep 
tissues. This syphiloderm rarely appears in the second, more often in 
the third or fourth, still more rarely in the fifth, tenth, or fifteenth year 
of the disease. 



SYPHILIS. 719 

Resolution occurs by resorption, leaving in the site of the tubercles 
according to their age, size, and contents, livid and pigmented macu- 
lations, or characteristic pigmented, atrophic, cicatriform areas. Scars 
following the ulcerative lesions are typical in color, shape, and career, 
the pigmentation of both cicatrix and areola blanching from centre to 
periphery, and leaving a delicate, dull-whitish, glazed, or slightly 
desquamating membranous new-growth ; ancient relics of this process 
resembling in appearance thin, small coin- and larger-sized, circular 
sheets of mica. 

Combinations of the tubercles of syphilis with other lesions have 
given origin to the differing terms employed in the designation of the 
eruptive phenomena in which the tubercle plays a frequent part. Thus 
papulo-tubercular, tuberculo-gummatous, papillomatous, or vegetating 
eruptions are so designated from the admixture of the several elementary 
lesions recognized in these forms of cutaneous syphilis. 

The rarer generalized forms are commonly of simpler type : the cir- 
cumscribed groups, whether serpiginous or limited to a single region, 
are more often variations from type and confusing to the untrained eye. 
The affected patch, for example, may be coextensive with the surface of 
an entire limb or buttock : or merely involve the nose and upper lip ; 
or possibly in irregular extension only the face. Whether of the reso- 
lutive or ulcerative class, the circumscribed patches commonly are 
sluggish in development and career, often sprinkled with superficially 
ulcerated points set in disks of atrophic or scar-formed tissue ; or again 
they furnish a ring of ulceration, deep or superficial, about a healing 
centre ; or a group of well-defined ulcers beset with nodules of papulo- 
pustular or papulo-tubercular type. The strictly serpiginous patch 
extends, whether from an ulcerated or partly healed centre, by advanc- 
ing a ridge of closely agglomerated or fused papulo-tubercles or tuber- 
culo-gummatous lesions, crusted, ulcerated, or merely resolving by 
degeneration when treatment has been pursued. The rupioid features 
seen in the larger pustular lesions are displayed here more rarely and 
less characteristically. Even in exaggerated types # of the serpiginous 
patches the process in untreated cases is one of advance, repair, ulcera- 
tion, and scarring in different grades at different points in the same 
area. It is of striking interest in the study of these cases to note that 
in almost every instance the disease either has been unrecognized and 
therefore untreated, or is one occurring in the subjects of cachexia, de- 
bauchery, or extreme poverty. Illustrations of these forms of cutane- 
ous syphilis are exceedingly rare among the cleanly and the well treated. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, acne 
rosacea, and psoriasis. In lupus the age of the subject, the character 
of any scars left upon the body-surface, the chronicity of the disease, 
and the absence of a history of polymorphism, will point usually to the 
nature of the disease. The tubercles of lepra are very much more indo- 
lent than those of syphilis, and have a characteristic oiled or varnished 
look, never the livid or dull-crimson color of syphilitic lesions. Set 
upon the forehead, the tubercles of syphilis, near the line of the hairs, 
never give the leonine aspect of those at the lower border of the fore- 
head and over the eyebrow of the leper. In epithelioma the age of the 



720 



NEW-GROWTHS. 



subject and the history of the disease are always significant. In the 
early stage of epithelioma characteristic " pearls " often may be recog- 
nized, while the patient may enjoy excellent general health, the imprint 
of cachexia often being distinct in tubercular syphilis of the skin. 
In the later stages of epithelioma the ulcer with everted edges and 
eroded, hemorrhagic floor, "varnished" with a translucent secretion, 
is totally different from the " punched-out " syphilitic ulcer with its 
pnriform secretion and discolored crusts. The deep infiltration of 
even the desquamating tubercular syphiloderm distinguishes it from 
the circular patches of psoriasis. In acne rosacea the telangiectases, 

Fig. 79. 




Syphiloma of the vulva with gummatous changes in labia and clitoris, and languettes of anus 
accompanying stricture of the rectum. • 

characteristic redness, and frequent pustular lesions are suggestive 
when considered in connection with the absence of ulceration. But, 
in both sexes, subjects of syphilis, with tubercles limited to the nose 
and head, in the middle periods of life often present themselves with 
marked rosacea from spirit-drinking, when the most careful examina- 
tion is needed to detect the coincidence of the two disorders. 



Syphiloderma Gummatosum. — The gumma is a lesion peculiar to 
syphilis ; no other disease exhibits an exactly similar feature. It is 
usually a late or so-called " tertiary " manifestation of the disease, but 
like all other symptoms of the disease may be of early occurrence. 



SYPHILIS. 721 

Gummata occur in two fairly distinguishable forms : the circumscribed, 
and the diffuse. 

Circumscribed Gummata develop as one or relatively few, subcuta- 
neous, strictly circumscribed, firm, well-rounded, painless, and indolent 
tumors or nodules, which, when first observed, are scarcely larger than 
a pea. They then are covered with an unaltered integument and are 
movable. 

Very slowly they may, when untreated, increase in size until they 
attain the dimensions of a marble, of an egg y or even of bodies of a 
considerably larger size. Sooner or later, when not resolved by treat- 
ment, they usually become attached, and the overlying skin is involved, 
showing by its livid, reddish, or purplish hue and its hypersemic 
areola that it threatens to yield. Finally, at one or at several points 
the skin is so thinned as to be incapable of further resistance, the gumma 
bursts, and a thick sanious secretion escapes, the gummy character of 
which has given the lesion its name. When the inflammation has 
been active its secretion may be wholly or partially purulent, and in 
this case be furnished either by the contents of the tumor or by the 
peripheral tissue which participates in the process. Ulcers always 
result, which occasionally are fistulous in type, roundish or oval in con- 
tour, with edges clean cut, and floor purulent and extending to the 
subcutaneous tissue, tendons, aponeuroses, cartilage, or bone. Thin 
and yielding bands or bridges of undermined skin often extend be- 
tween several such solutions of continuity, and usually melt down in 
the presence of the destructive process. When repair is progressing, 
which is the rule as regards the ultimate result, granulations spring 
from the floor of the ulcer, the edges contract, and -the gummatous 
eventually exhibits the appearance of a simple ulcer, save in the thinned 
purplish, pigmented appearance of the outlying integument. The scars 
are typical, pigmented at first and bleaching from the centre, and 
they may be attached to periosteum or bone, though this is exceedingly 
rare. Considering the depth of the process, the gumma of the skin is, 
as a rule, succeeded by less evidence of destruction than is threat- 
ened at the height of the process. About the neck, cicatrices may be 
linear in shape and slightly puckered. Upon the extremities and the 
trunk they are usually circular or oval. 

But one gumma may appear upon the person of a single individual, 
and when this is the case it will usually be found upon the leg. Half 
a dozen or more may at times coexist. In other cases hundreds form. 
Gummata may develop upon any part of the body, more particularly 
over the face (head, nose, lips), the thighs, legs, and arms, the scalp, but- 
tocks, and genitalia. When situated over the trunk of a nerve they may 
become the seat of severe neuralgic pain. They are amenable to skilful 
treatment, and they may undergo resorption, leaving little or no trace 
of their former existence. 

Diffuse gummatous infiltrations of the skin and hypoderm are 
either distinctly contoured, which is the rule ; or ill-defined at the 
border, varying in extent from a coin-sized patch to an irregularly out- 
lined infiltration coextensive with the integument of an entire limb. 
The central portion and borders of such an area may be constituted of 
46 



722 NEW-GROWTHS. 

partly fused originally discrete lesions, as in the instance of papulo- 
tubercular lesions, or be made up of a thick or thin plate of infiltration, 
here and there either threatening ulceration or besprinkled with actively 
ulcerating points. In extreme cases these losses of tissue are deep and 
vast, furnishing the picture of a group of typical syphilitic ulcers having 
a sloughy floor and precipitous edge. The patch or patches often form 
curiously outlined parts of circles in the classical figures of the letter S, 
the horseshoe-shape, the kidney, etc., these composite groups including 
equally sized circlets of infiltration with border-ulcers ; or a larger cen- 
tral patch with gummatous infiltration is surrounded by smaller patches 
set circle wise about the former, as in the arrangement of pearls in a 
brooch. In less classical features there is presented the rare picture of 
a swollen, engorged, almost elephantiasic organ (leg, vulva, nose), 
crusted, corded, ridged, knobbed, and seamed with smaller or larger 
ulcers and scars. 

Gummata are to be distinguished from fibrous, carcinomatous, and 
lipomatous, tumors, as also from indurated and enlarged lymphatic 
ganglia. As gummata of the skin occur in preponderance below the 
level of the knees, and are for the most part single or relatively few in 
such situation, by their position alone they frequently can be differen- 
tiated from each of the new-growths mentioned, no one of which occurs 
by preference upon the lower extremities. As they are, moreover, 
relatively late lesions of syphilis, a history of pre-existing symptoms of 
that disease usually can be obtained. 

The element of time is of chief importance in the diagnosis, as the 
evolution of gummatous syphilis is more rapid than that of most tumor- 
forming affections. The characteristic " pearls " of epithelioma and its 
situation chiefly on the face will serve to suggest the diagnosis when 
there are gummatous lesions of the extremities. Lupus of the extremi- 
ties is rare. Gummata of the face are confused most often with the 
two disorders named above. Invariably in all doubtful cases in the 
male sex the testicle should be examined, as frequently a tell-tale gum- 
matous infiltration of the epididymis or testicle proper, unrecognized by 
the subject of the disease, clears up the doubt. 

Erythanthema Syphiliticum.— Under this title Bronson l de- 
scribed a condition observed by himself in syphilitic patients. Upon a 
well-defined, crimson or livid, erythematous surface (face, palms, soles) 
appeared an abundant crop of pea-sized vesico-pustules, which were con- 
verted later into an exuding, whitish, elevated, diphtheroid patch. The 
multiformity of the exanthem was characteristic. In parts it suggested 
the hydroa bulleux of Bazin ; in other parts the dermatitis herpeti- 
formis of Duhring. The fluid exudation that affected the face was not 
characteristic of the evolution of the palmar and plantar lesions. 

Later, warty, papilliform lesions appeared over the face and neck, 
somewhat resembling secreting condylomata, and surmounting for the 
most part a dusky-red or erythematous surface. 

This author regarded the exanthem as primarily a syphilitic product 
but not pathologically or etiologically a true syphiloderm. Its origin 
1 N. Y. Med. Record, 1886, xxx, p. 253. 



SYPHILIS. 723 

was possibly similar to that of the angioneurotic, trophoneurotic, or 
reflex phenomena of skin-disorders in general, though possibly due to 
bacterial invasion. 

Syphilis of the Mucous Suefaces. 

The lesions of syphilis involving the mucous membranes, found 
chiefly in the mouth, but exhibited, also, in both acquired and infantile 
disease, over the nasal, aural, vaginal, anal, and balano-preputial sur- 
faces, are strictly allied to the similar symptoms in the skin. The 
differences are due to maceration of the involved surfaces, to the func- 
tions of the organs chiefly implicated, to contact, and to apposition of 
contiguous parts. 

There is, hence, every grade of disorder from hyperemia to inflam- 
mation ; and the results of the latter are both ulceration and cicatriza- 
tion, each result being subject to the special modifications due to the 
syphilitic process (gummatous deposits, infiltrations, etc.). 

In the purely hypersemic forms there is usually at the moment 
or soon after the outbreak of general syphilis a pharyngeal or a phar- 
yngo-nasal blush, spreading symmetrically or irregularly over the parts, 
accompanied often by engorgement of the tonsils, especially in persons 
previously subject to disorders of the same region due to other causes 
(catarrh, follicular tonsillitis, etc.). There is then pain on swallowing, 
and complications may arise, producing laryngeal hoarseness, cough, 
dyspnoea, aphonia, nasal discharges, crusts blocking up the passages 
(especially in inherited disease), and impeded transmission of air 
through the nares. Similar conditions may be observed about the os 
uteri, the peri-anal region, and others of the sites named above. This 
may or may not be the precursor of the severer complications — mucous 
patches, ulcers, and other symptoms of syphilis of mucous surfaces. 

Mucous Patches (Condylomata ; Fr., Plaques muqueuses ; Ger., 
Schleimhautpapeln, Feigwarze) are merely syphilitic papules occurring 
in moist situations, flattened by reason of the apposition of affected 
surfaces and by contacts necessitated by the functions of the parts in- 
volved. They form upon all mucous surfaces, but especially in the 
mouth, where they are the most annoying and the most persistent 
symptoms of syphilis, complicating both the early and the later stages 
of the disease. 

The patches are roundish or oval, tumid, flattened or very slightly 
depressed, pale-rosy or whitish spots, moistened with mucus, either devel- 
oping as such or resulting from hypersemic plaques of the sort described 
above, or dispersed among or upon the latter. They often resemble 
the patches produced on the mucous membrane by pencilling the latter 
with a crayon of silver nitrate. When carefully inspected, many of 
them exhibit a loosened and partially detached film of membrane, cov- 
ering the tissue, beneath which a reddish, raw-looking surface appears. 
They are seen not merely upon strictly mucous surfaces, but develop 
also on the verge of the latter (mouth, anus, scrotum), and even on 
moistened cutaneous surfaces — the edges of nails in infants, and in 
persons whose hands are often macerated, between the toes., in the 



724 NEW-GROWTHS. 

vulvocrural angles, etc. The condyloma is described by many writers 
separately, but the older authorities were by no means in error when 
using, as appears above, the term " condyloma " for both the mucous 
patch and the flattened creamy-looking secreting papules seen often 
about the anus and the vulva of the subjects of syphilis, particularly 
those of a tender age ; for the condyloma is actually a flattened syph- 
litic papule, as is the mucous patch, the external appearances of which 
are chiefly the result of its site and surroundings. 

The secretions of these lesions are at times very offensive in odor, 
especially about the anogenital region, but also about the mouth and 
the nose (infants, the filthy, and the neglected). They may become 
fissured (edges of the tongue, tonsils, vagina), may ulcerate deeply, 
may be the seat of vegetations (papilloma, so-called " esthiomene of 
the vulva," etc.), and, in general, may furnish a highly contagious 
secretion. It is probable that mucous lesions are more responsible for 
the transmission of contact-syphilis than are chancres. 

Mucous lesions are to be distinguished with care from simple aphthous 
patches in the mouth the result of indigestion or local disturbances ; 
also from smokers' patches (leucoplakia buccalis, " psoriasis linguae," 
leucoplasie and from lichen planus of the mouth. In external features 
these patches may resemble one another, but in only one affection, 
syphilis, are there other signs of infectious disease. The chief points 
of difference are : singleness, for the most part, of aphthous sores, and 
often exquisite tenderness ; multiplicity, as a rule, of mucous patches, 
and much less soreness, though when ulcerated the soreness may be a 
conspicuous feature. Linear streaks and bands (often quite insensitive) 
of leucoplasie patches are found especially along the gums, on the 
lines of the inner cheek representing contact with the approximated 
upper and lower teeth, and in the pocket posterior to the wisdom tooth. 
The flattened and often isolated patches of lichen planus of the tongue 
have an almost characteristic lead-white color. 

Scaly Patches, described by most authors separately, are not true 
mucous lesions of syphilis. They occur not rarely in syphilitic subjects 
as flattish, smooth, bluish-white or lead-white, firm, slightly indurated, 
and roundish or highly irregular plaques. They are visible on the 
dorsum of the tongue, on the mucous lining of the cheeks, and at the 
angles of the mouth, where they are situated often in part on the mucous 
surface and in part on the skin of the lip. The thickened epidermis 
is at times covered with adherent, not readily removed, scales between 
w r hich fissures form, and the patch, at first almost insensitive, becomes 
exceedingly tender and painful. 

These patches are for the most part of the order described above, 
that is, leucoplasie, due chiefly to irritation of the mucous surfaces by 
tobacco-smoke, yet occurring in syphilitic subjects, as they are preceded 
often by typical mucous patches. They are almost exclusively seen in 
men. They are also rarely encountered in inherited syphilis. In the 
distinction sought to be made between the specific and the non-specific 
form attention is called to the occurrence in the latter class of hard, 
uneven, and considerably thickened patches, which occasionally prolif- 



SYPHILIS. 725 

erate, and which, extending to some depth, are eventually transformed 
into epitheliomatous lesions. 

Gummatous infiltrations of mucous membranes ("sclerosis of the 
tongue," of Fournier) occur in both circumscribed and diffused forms, 
superficial and deep. In the diffuse superficial forms both the mucous 
and the submucous tissues are involved in a firm thickening, best studied 
on the surface of the tongue, which then becomes to the view polished 
and smooth, at times appearing as if covered with a thin, translucent 
varnish. Patients exhibiting this condition will often describe a sub- 
jective sensation of " slipperiness." These thickenings may involve 
the deeper structures by every gradation, producing eventually lobu- 
lated masses with intervening fissures, tender, raw, and excoriated. 
The general face of the tongue is then, as a rule, covered with a par- 
ticularly foul, dirty-grayish coat, and it is occasionally notched at the 
edge with deep ulcers. At times the tongue is mottled, with patches 
of redness alternating with the yellowish white of the deposit on the 
surface of the membrane, but more rarely the lip is covered with florid 
verrucous filiform growths. 

The deeper gummata involve the body of the tongue, and they are 
felt as submucous, diffuse or circumscribed, dense thickenings (usually 
tolerably well defined), which soften, ulcerate, and leave exposed to 
view extensive losses of substance. The floors of these excoriations are 
deep ulcers, indurated, sloughy, and with membranous shreds over the 
surface. The fissures of the sides of the tongue described above may 
here also produce deeply ulcerated notches in the substance of this 
organ. Deformities of this class are relieved markedly after cicatrization, 
even when considerable loss of tissue has resulted. 



Syphiloderma Infantile Acquisitum et H^ereditarium. 

Syphilis may be acquired by the infant or child at any period after 
birth, as, for example, by immediate contagion from the nipple of the 
nurse, or mediately, as by the use of utensils smeared with a secre- 
tion capable of transmitting the disease. Such acquired infantile dis- 
ease displays, for the most part, the symptoms observed in adult years, 
except that the delicate and tender skin at this early period of life 
often exhibits the moist and secreting lesions of syphilis. The mu- 
cous patch, the pustule, and the condyloma are here more common 
than the papulo-squamous symptoms of the adult. Some influence is 
also exerted upon the disease by the dress, habits of life, and mode of 
obtaining nutriment, which are conditioned upon the helplessness of 
the young child. In this way the soiled napkin over the anogenital 
region, the warm covering of, and free diaphoresis from, the general 
surface of the skin, and the frequent contacts of the lips with the 
nipple, suffice to determine in special regions particular local expres- 
sions of the constitutional vice. The acquired is much less grave in 
character and portent than the inherited form of the disease. 

Hereditary syphilis, which may be displayed first in infancy or in 
early adult years, is always strictly transmitted by inheritance from one 



726 NEW-GROWTHS. 

or both parents. The consideration of the disease in these pages being 
limited to its cutaneous manifestations, it is first to be noted that the 
infected foetus may prematurely be expelled dead-born with cutaneous 
symptoms displayed upon its body-surface. Over 90 per cent, of 
the products of conception affected with inherited syphilis perish in 
abortions. 

This condition generally argues in favor either of intense syphilis 
in one or both progenitors, or, more commonly, of relatively recent 
infection of both. Under these circumstances there are usually evi- 
dences of the death of the foetus at some date prior to its expulsion, 
the skin being macerated and the epidermis raised from the corium in 
few or many bullous lesions, beneath which the derma exhibits a livid 
reddish or a purplish hue. 

When the infant is born with a clean skin it may be shrivelled and 
emaciated, or be fat and present the appearance of sound health. 
Soon after birth, however, cutaneous manifestations appear, usually 
before the conclusion of the first month, less commonly during the 
second, rarely after the third and the fourth. The earlier the date of 
such explosion the more intense, as a rule, is the evidence of the 
disorder. The first symptoms displayed are significant of visceral 
involvement, and are, in brief, those of marasmus. Emaciation pro- 
gresses rapidly ; the skin seems stretched unnaturally over the facial 
bones ; the expression is that of physical distress ; the cry becomes a 
fretful moan ; the integument loses entirely the rosy hue of the healthy 
infant, and acquires instead a sallow or muddy tint ; and very peculiar 
wrinkles or puckered lines radiate from the angles of the lips. Few 
observers have failed to notice the resemblance which then exists 
between the faces of these emaciated little creatures and those of the 
aged of both sexes. 

In this complexus of symptoms, however, there is absolutely nothing 
characteristic of syphilis as distinguished from other wasting diseases 
of infancy. Chronic tubercular meningitis and the gastro-intestinal 
disorders of infancy in their extreme expression furnish a precisely 
similar picture. This is natural enough, since all depend alike upon a 
similar cause, failure of proper performance of function on the part of 
the viscera in consequence of morbid changes. 

The coryza of the syphilitic infant, however, is soon declared, and 
speedily gives a clue to the nature of the morbid process. The dis- 
charge from the nares (at first serous, later purulent) desiccates suffi- 
ciently to obstruct the nasal passages or, in consequence of the tumid 
condition of the membrane lining the passages, is prevented from 
escaping. Often this discharge is furnished by a specific rhinitis chiefly 
invading the Schneiderian membrane. At times crusts accumulate 
externally about the nasal orifices, and they are seen to be similar to 
those which are prone to form also at the angles of the mouth. In this 
way the characteristic " snuffles " of the syphilitic infant are induced, 
in consequence of which it is obliged when nursing to release the 
nipple from its mouth in order to respire, an act often accompanied by 
a hoarse cry. The breathing of the syphilitic infant, even when 
asleep, or awake and undisturbed, is often sufficient to arouse a sus- 



SYPHILIS. 727 

picion as to the nature of the disease from which it is suffering. The 
mouth, the larynx, the vulva, and the anus are often the seat of similar 
lesions, the development of which into an obstructive tumefaction 
secreting more or less profusely, or into moist condylomata, will largely 
depend upon the seat and surroundings of the lesion. 

The cutaneous symptoms of inherited syphilis are macular, papular, 
pustular, bullous, or furuncular, two or more of them being at times 
commingled, attesting thus the identity of the disease with the poly- 
morphic acquired forms of maturer years. Macules early appear upon 
the trunk, the face, the neck, and the extremities, usually of a livid 
reddish hue, commingled with papules, and indeed often occur as the 
first manifestation of the papules. They are irregular as to shape, 
and though occasionally pinkish, discrete, circinate, and coffee-bean- 
sized, often produce a diffuse, coppery-red or violaceous, glazed or 
moist and secreting surface, affecting an entire region, as the neck, the 
trunk, or the thighs and the genitalia. Often the palms and soles are 
invaded. Deep excoriations and even fissures occasionally form in 
these extensive patches, and the secretions may incrust them irregularly, 
the general aspect of the patch somewhat suggesting an eczematous 
condition, yet remarkably differing from it in color. 

In hereditary as in acquired syphilis the type of all the eruptive 
symptoms is to be sought in the papules which may spring from tk.2 
macules described above, and develop into pustules, bullae, or condy- 
lomata ; and, in the former case, dull-red or violaceous papules of 
lenticular size occur either in asymmetrical or symmetrical arrange- 
ment, being discrete or agglomerated in patches of infiltration. These 
papules may, especially upon the buttocks, scale at the apex ; or, par- 
ticularly upon the palms and soles, may constitute by fusion a thickened 
desquamating epidermal patch ; or, commonly about the anogenital 
region, the interdigital spaces, the axilla?, and face, may become moist 
and secrete a puriform mucus. By vegetation or by hypertrophy they 
develop into flat or fissured condylomata, smeared with an offensive, 
yellowish or yellowish-white discharge ; and vary in size from that of a 
small coin to a lesion a centimetre or more in diameter, with correspond- 
ing variation in the degree of their elevation from the affected surface. 
Condylomata may be few or numerous. Sometimes a child will appear 
to be well-nigh covered with large, moist, secreting papules. Papulo- 
condylomata may deeply ulcerate and crust. It should be remembered, 
in studying these symptoms, that they are those of a cachectic infant 
affected with a grave disease. Death often interrupts the sequence of 
the manifestations above described. This event is usually preceded 
by signs of apparent amelioration, shrinkage of hypertrophic growths, 
and decoloration of hypersemic lesions and patches. Of the other 
cutaneous symptoms of hereditary syphilis, vesicles are the rarest ; the 
smaller, occasionally seen, have a conical apex with serous contents, are 
closely set together about the lips, and spring from a violaceous infil- 
trated patch. The resulting crusts never have the reddish-yellow tint 
of those observed in eczema, nor, after rupture, are they followed by 
serous oozing from a wounded epidermis. The larger lesions of this 
sort are usually transformations of papules which rapidly assume a 
pustular phase. 



728 NEW-GROWTHS. 

Pustular eruptions, in this form of syphilis, may be discrete or be 
confluent, localized or generalized. They are particularly prone to 
occur in groups about the mucous outlets, with maculo-papular lesions 
developed elsewhere, and they may result in ulceration, often after 
development into bullae with pustular or sanious contents. The 
resulting crusts are bulky and dark colored, and, especially upon the 
face, disfiguring. The subjective sensations are insignificant, since 
the child does not attempt to tear the affected surface as in pustular 
eczema. The cachectic condition of the little patient is usually pro- 
nounced when these lesions are large and numerous. They may be 
seen in typical development by the side of the nail, occasionally involv- 
ing the matrix, and producing in this situation considerable swelling of 
the digit, with an ulcerative sequel which commonly results in distor- 
tion or an ultimate loss of the nail-substance. Onychia, however, may 
result from perverted nutrition of the part, with increase in the fria- 
bility of the nail-substance, loss of lustre, assumption of a dirty-grayish 
hue, and phalangeal oedema. These changes are analogous to those 
resulting in loss of the hair where the follicles have been improperly 
nourished. 

The furuncles which form in other cases are either exaggerated 
manifestations of the same pyogenic tendency in the skin of the infant, 
a complication common to syphilitic and other cachectic conditions in 
young children, or are the result of infection with pus-cocci, a more 
frequent cause. These furuncles may be few or be numerous, and they 
are characterized chiefly by their indolence, the ill-conditioned pus in 
their contents, the ulcerative condition left after their evacuation, and 
the bluish or purplish condition of the integument which surrounds 
their edges. 

Bullae in hereditary syphilis are early or late manifestations of the 
disease, and they may be represented by a single lesion on the palms 
or soles (the site of their predilection), or they may constitute a sym- 
metrical generalized efflorescence. Bullae should be regarded as evi- 
dences of a grave form of the disease, being often the precursors of a 
fatal issue, as indicating a feeble resistance on the part of the epidermis 
to the fluid exudate furnished from the corium beneath. In severe 
cases the bullae are ill developed, and the integument will be seen to be 
marked here and there by small coin-sized and larger disks or plaques 
of macerated epidermis, separated from the derma by a thin film of 
serous, sanious, or purulent fluid, in quantity insufficient to raise the 
roof above the general level of the integument. When fully developed 
they may be conical, rounded, flat, or flaccid, and be surrounded by an 
infiltrated border of dark-reddish or violaceous hue. Their color varies 
with the color of their contents. Their subsequent career is concluded 
by shallow or by deep ulceration, the base of each bulla secreting a 
sanious discharge. Crusts may form if the patient survives. A fatal 
termination of the disease is usually announced by flattening or collapse 
of the blebs. The lesions may be commingled with pustules, maculo- 
papules, condylomata, and mucous patches of the anus, the mouth, and 
the nares; but they are somewhat different from the other lesions 
described in that they may constitute a uniform efflorescence, no other 



SYPHILIS. 729 

cutaneous symptoms being manifested. The uniformity is due to the 
fact that bullae represent the state of feeblest resistance in the epidermis, 
the fluid exudate of exceedingly low grade mechanically separating the 
rete from the tissues beneath. 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but only as late manifestations of the disease, one or more 
years elapsing before their appearance. Their behavior is scarcely dif- 
ferent from that of those observed in the acquired forms, although the 
destruction wrought by their degeneration in very late manifestations 
may be of the most intractable type. Usually there is a history of 
preceding parental or inherited disease, and coincident symptoms or 
sequels of such disease, in altered teeth (as described by Hutchinson), 
in an ancient keratitis, or in a hopeless form of surdity. 

The special deformity of the teeth first described by Hutchinson 
involves the permanent upper central incisors which when first erupted 
are short, narrow, and thin, but later, by attrition of the free edge, 
present a broad shallow vertical notch. The teeth sometimes converge, 
sometimes are set widely apart and have a dirty hue. These teeth are 
not, as often has been assumed erroneously, pathognomonic of inherited 
syphilis, but occur typically in the permanent teeth of children and 
adults affected with other disorders. 

Mucous patches are very constant symptoms of the disease, and they 
represent papules of the mucous membrane that differ from those seen 
in the skin only because they are moistened, macerated, and flattened 
by juxtaposition of neighboring tissues. They are surrounded usually 
by a lurid halo, and they may have the pearly whiteness always seen 
when the epidermis of mucous membrane is wholly or partly detached 
from the corium; or they may lose this protecting disk in shreds or 
patches, and show, beneath, an engorged or ulcerated and secreting 
tissue. They may be isolated or be broadly confluent, and be oval, 
circular, or decidedly linear in shape, the last-named appearance being 
characteristic of patches existing at the angles of the mouth. Mucous 
patches are to be recognized as distinct from both the parasitic and the 
non-parasitic forms of simple stomatitis or thrush, the parasitic form 
being due to the presence of the o'kUum albicans. In both of the non- 
syphilitic disorders the mouth of the child is very generally, uniformly, 
and symmetrically involved, the circumscribed patches being distinctly 
discrete and resembling in color soft whitish or yellowish flocculi of 
curdled milk. They occur not merely in the mouth, but in the ano- 
genital region, between the toes and the fingers (especially the former), 
in the axillae, groins, buttocks, and folds of the neck. 

The diagnosis always is aided greatly by noticing the well-nigh con- 
stant occurrence of patches at the angles of the mouth, which has also 
the seamed and puckered appearance described above. Snuffles, syph- 
ilodermata, and marked cachexia, when established, leave little doubt as 
to the nature of the malady. In all cases when suspicion arises the 
infant should be stripped of its clothing, its entire surface be inspected 
carefully ; all accessible bones be traversed by the fingers, the shape 
of the skull studied, and, in the case of male infants, the testes examined 
for gummatous infiltration. 



730 NEW-GROWTHS. 

The future of the infant aifected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired, form of the disease benignancy may be in 
rare cases a conspicuous feature of the entire process. The evolu- 
tion of the disease may be tardy ; its symptoms be few and unimpor- 
tant; its amenability to judicious treatment speedily be demonstrated. 
Still, the fact remains that the disease when inherited is far graver than 
when acquired, the victim of inheritance entering the world with its 
viscera and bones subject to profound pathologic alterations. Atten- 
tion has been directed to the important fact of the frequency with which 
the syphilitic product of conception perishes. 

Etiology. — Syphilis, in the course of which appear the syphilo- 
dermata, is produced by either accidental or intentional infection, or 
as a result of heredity. In all cases it is believed that the contagium, 
which reaches the blood through the medium of the lymphatics, 
is effective by reason of a virus charged with a pleomorphous but 
as yet undemonstrated bacillus. The physiological secretions of the 
infected uncontaminated with pathological products are believed to be 
incapable of acting as virus-carriers, but, especially in the recently 
infected, such contamination is of frequent occurrence, and is generally 
effective in the transmission of the malady to persons not immunized 
by previous attacks of the disease. 

The methods of transmission may be immediate, as in sexual con- 
gress, in kissing, and in nursing at the nipple, by which act the child 
may infect the nurse with the secretion of the mucous patches in its 
mouth ; or it may, instead* receive the disease from the excoriations on the 
breast of the nurse. The disorder may also result through the medium 
of utensils charged with an infectious secretion, such as the needles of 
the tattooer wet with saliva commingled with diseased mucus, or the 
lancet of the vaccinator covered with an intoxicated blood. Generally 
it may be said that all the discharging and moist syphilodermata are 
sources of danger to a sound individual, both in the acquired and 
the inherited forms of the disease. 

By these and other similar methods persons of both sexes and all 
ages may become infected. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration of the dance, will often invite to the surface a macular 
syphilide which might otherwise be less fully developed ; friction, as 
by the hatband over the forehead, the cuff at the wrist, and the shoe 
upon the foot, demonstrates its influence by daily examples of deter- 
mination of the morbid process to special localities. In the trades 
the hands of the syphilitic laborer betray unmistakable evidences of 
the irritative effect of harsh contacts ; the same may be said of filth, 
such as the feces on the napkin of an infant that frequently provoke 
condylomata in the anal region. It is a mistake to suppose that syph- 
ilis, and syphilis only, is responsible for the exanthemata of that dis- 
ease in all shades, grades, and situations. Soap and water are as efn- 



SYPHILIS. 731 

cient in preserving the skin of the syphilitic as of the sound subject ; 
and the infected tobacco-chewer pays a price for his nauseous habit. 
Poverty, misery, and wilful neglect or ignorance of the laws of hygiene, 
are responsible for a long and lengthening list of the complications of 
the disease. 

Pathology. — The search for the micro-organism responsible for 
syphilis has been conducted by numerous and skilful observers. Be- 
ginning with Donne in 1837, the list includes the names of Hallin 
(1869), Salisbury and Briihlkens (1870), Klebs, Lostorfer, Bermann, 
Cutter, Aufrecht, Obraszow, Lustgarten, v. Niessen, and others. 1 
More lately these have been followed by Max Schiiller, who believes 
that he has discovered the cause of syphilis in a protozoon occurring in 
chancres, which passes through a developmental stage, after which 
there is a formation of spore-capsules which traverse the blood- and 
lymph-channels. These bodies produce in cultures pigmented and 
ciliated parasites in which contraction-movements have been seen. 

The microbe described by Jullien and de Lisle was obtained only 
from fresh blood-plasma, being destroyed immediately, according to 
these authors, in coagulated blood. The bacillus is polymorphous, 
varying from 5 to 8 /j. in length, and becoming at times an elongated 
motile filament with rounded ends not capable of receiving stains by 
the Gram method, but staining with ordinary colors and cultivated 
readily on broth, gelatin, agar, glycerin-potato, and the amniotic fluid. 

Joseph and Piorkowski have ventured on a new method of explora- 
tion by employing placental tissue as a culture-medium. After inocu- 
lation of the placenta with the sperm of syphilitic patients they discov- 
ered a motile bacillus having the general shape and appearance of the 
diphtheria-bacillus and as minute as the bacillus subtilis, not acid- 
proof, rapidly degenerating, and receiving stain by the Gram method. 
Afterward it was cultivated in generations on ordinary media ; was 
found in some forty cases under observation ; and was not recognized 
in control experiments with healthy sperm. Inoculation of swine 
with the cultures of this organism was followed by inconclusive results. 

The micro-organism which produces chancre is undoubtedly present 
in many of the syphilodermata, while its toxins circulating in the 
blood are certainly the immediate cause of other lesions. Pustules in 
this disease in many instances are due to secondary infection, while the 
crusted, scaling, and other syphilides are often the result of coexistence 
with syphilis of seborrheal eczema or other inflammatory dermatoses. 

While the histological changes in syphilis cannot be considered 
pathognomonic, practically all the lesions, including chancre, show the 
same structure and processes, varying somewhat in extent, intensity, 
and in minor features, due to the circumstances of location, state of 
nutrition of the tissues, and the virulence of the infecting virus. The 
processes are always chronic in career. There are always hyperemia 
and more or less dense infiltration, chiefly about the vessels. Herzog 2 

1 Joseph and Piorkowski, Berlin, klin. Wchnschrft., 1902, xxxix., pp. 257 and 282; 
and Deutsch. med. Wchnschrft., 1902, xxviii., p. 898; Schiiller, Max, Zeitschrift, 1903, 
x., p. 333; de Lisle. Justin, Amer. Med., 1903, vi., p. 474. 

2 Brit. Jour. Derm., 1899. 



732 NEW-GROWTHS. 

and Rieder agree that the vascular changes in syphilis chiefly concern 
the veins and lymphatics, the arteries being relatively free ; and that 
the vascular infection proceeds through the lymphatics from the peri- 
vascular lymph-spaces. The inferiority of the veins in point of 
resistance is supposed to explain the difference in susceptibility of the 
venous and arterial systems. After a general outbreak, either with or 
without antisyphilitic treatment, hematogenous immunity is secured for 
the time being. 

The cells of the syphilitic new-growth are lymphoid in type. 
There is usually endothelial proliferation. In the solid lesions (papu- 
lar, tubercular, and gummatous) the microscopical appearances are 
practically those of tuberculosis, including the presence of giant-cells. 
The neoplasm is not capable of organization, but undergoes involution 
either by fatty degeneration and absorption of the cells or by necrosis 
and ulceration. According to Jullien, the three characteristic features 
of all syphilides are the cell-infiltration, the inevitable destruction of 
this infiltrate the cells of which are incapable of organization, and the 
centrifugal development and retrogression of the neoplasm. 

In the macular syphilide the process is superficial and circumscribed. 
There may be simply hyperemia, stasis, and effusion of serum with 
slight infiltration about the vessels of the papillary and subpapillary 
layers. These vessels are dilated, and show endothelial and perithelial 
proliferation. There is often a periglandular and perifollicular infiltra- 
tion of lymphoid cells, and the coil-glands not infrequently show a 
swollen epithelium. In the urticarial type of macule both the epi- 
dermis and the upper part of the cutis may show oedema. In the older 
and thickened macules the structure gradually approaches that of the 
papule. 

In the several forms of the papular syphilide the cell-infiltration is 
pronounced in the papillary layer and about the vessels, but extends 
also to the deeper portions of the cutis. There is more dense peri- 
follicular and perivascular infiltration than in the macule. A few 
epithelioid and young connective-tissue cells are seen, as also occasional 
typical giant-cells. Unna describes the new-growth as made up chiefly 
of plasma-cells of different sizes. The papular syphilide exhibits a 
larger number of incomplete giant-cells, a different arrangement of the 
plasma-cells, and more spindle-cells, together with a better preserva- 
tion of the fibrous tissue along the lymphatics, than are seen in lupus. 
The firmness of the papule is due to a decided increase in fibrous tissue 
occurring with the cellular growth. The normal structure of the 
tissues and the dividing-line between the cutis and epidermis may be 
effaced by the excessive multiplication and infiltration of cells. Dila- 
tation of bloodvessels with endothelial and perithelial proliferation 
occurs. The coil-glands show swollen epithelium, which may multiply 
sufficiently to block the canal or even to obliterate it. 

The infiltration is often most marked about the hair-follicles, and 
may penetrate the root-sheaths, sometimes destroying the hair-papillse 
and sebaceous glands. There is frequently a deposit of pigment in the 
basal layer of the rete, and sometimes in the corium. The connective 
tissue is rarely involved, and in the majority of papular syphilides the 



SYPHILIS. 733 

infiltrate is absorbed and leaves no scar. Involution of the deeper and 
more persistent papules, however, may be followed by atrophic scars. 
The epidermis is involved secondarily, and may be thickened and 
exfoliated or thinned and atrophied. On the palms and soles the 
papules are broad and flat, due to mechanical pressure of the natu- 
rally thick and firm epidermis that is closely attached to the deeper 
tissues. Here, and occasionally in other parts of the body, there may 
be a persistent thickening and exfoliation, due probably to a secondary 
inflammatory process, for months or years after all traces of the origi- 
nal cell-infiltration have disappeared. In the anal, genital, and other 
regions where the papules are subjected to the influence of warmth, 
moisture, and friction, large, flat condylomata may develop in which 
the original histological structure of the papule may be largely obscured 
by the secondary and extensive hypertrophy of the rete, which sends 
broad processes deeply down between the papillae, though over the 
apices of the latter it may be thinned. (Edema of both corium and 
rete with dilatation of lymph-spaces and leucocytic infiltration is 
usually pronounced. 

Moist lesions (vesicles, pustules, bullae) are of exceptional occurrence 
in syphilis, being seen chiefly in the very young, in the very old, in 
cachectic subjects, or as the result of accidental and secondary infec- 
tion. These moist lesions form, as a rule, at the apices of the papules, 
and in some cases are caused apparently by an unusual intensity and 
rapidity of the process. Destruction of the cells in the centre of a 
papule may result in a pustule or superficial ulcer. The coexistence 
of seborrhoea in some of its phases is responsible for the crusting of 
many of the papular and tubercular syphilides. 

The tubercular syphiloderm is practically identical in structure 
with the papule, but is larger, and is seated deeper within the derma. 
The connective-tissue hypertrophy is greater proportionately than in the 
papule, the fibres of the papillae being much thickened, the blood-vessels 
and lymph-vessels greatly dilated and their walls hypertrophied. As 
in the papule, the epidermis is secondarily involved, and atrophic 
changes are of frequent occurrence. The tubercular syphiloderm is 
slower of evolution and more persistent than the papule, hence the 
mere mechanical pressure of the neoplasm frequently causes destruc- 
tion and atrophy of the normal tissue, and the involution of the 
tubercle in such cases is followed by an atrophic scar. Necrosis of 
the cells in the centre of the tubercle may result in the formation of a 
small ulcer. Peripheral extension with coincident degeneration and 
absorption or necrosis and ulceration of the central portion may occur, 
as in all syphilitic processes. The neoplasm is commonly circum- 
scribed, but may be diffuse. 

The gumma corresponds closely to the tubercle in structure and in 
career ; but is larger, and is seated chiefly in the subcutaneous tissue, 
involving the skin secondarily. 

Diagnosis. — According to Justus, a diagnostic test of syphilis 
is the sudden decrease in haemoglobin which immediately follows 
the inunction or injection (not the ingestion) of mercury in full 
doses. 



734 NEW-GROWTHS. 

The syphilodermata are to be distinguished from all other cutaneous 
eruptions by their general characteristics and by the features peculiar 
to each lesion. It must not be forgotten, however, that these lesions 
are not essentially different in character from all others, but are to be 
recognized with ease or with difficulty according as they do or do not 
betray the syphilitic expression. No one, however expert in diagnosis, 
can always trust himself in a doubtful case to recognize these special 
features by a study of the eruption only, at a given moment of time. 
Neither in respect to color, form, size, situation, disposition, or other 
peculiarity do the syphilodermata exhibit an absolute difference from 
non-syphilitic affections of the skin. It is, therefore, requisite in every 
case to investigate in the fullest manner the history of the disease, of 
all prior skin-lesions, of a primary sclerosis (when this can be obtained), 
of adenopathy, miscarriages, abortions, and disorders affecting other or- 
gans of the body, as the bones, the viscera, the organs of sense, and the 
mucous surfaces. Often a single extra-cutaneous symptom is a valuable 
aid in establishing the diagnosis of syphilis. An " eczematous " infant 
with snuffles and a hoarse cry has been treated in vain by many a phy- 
sician, otherwise capable of making a diagnosis, who might have been 
given a clue to the nature of the disease from which the child was 
suffering if he had taken pains to inspect the anus and question the 
father in private. It is especially noteworthy that syphilis is verv 
rarely a disease with cutaneous symptoms only. The bones, viscera, 
testes of male patients, and mucous membranes rarely fail to give evi- 
dence of systemic infection when lues has existed for any length of 
time with active cutaneous manifestation. 

Every syphilitic patient with a disease of the skin does not neces- 
sarily exhibit syphilodermata. The course of the disease in many cases 
is so protracted that patients have ample opportunities to contract other 
disorders, and their number is larger than is commonly supposed. 
They suffer most often from the medicamentous eruptions, especially 
those induced by the ingestion of potassium iodide (cf. the chapter on 
Dermatitis Medicamentosa : Drug-eruptions from Salts of Iodine) ; they 
are, like other men and women, bitten by bugs and lice ; and they 
suffer from eczema, acne, psoriasis, and other non-venereal disorders. 
This common susceptibility is less true possibly of the innocent victims 
of the disease than of those guilty of sexual excesses in and out of the 
married state, many of the unmarried leading the most disordered lives, 
and exposing themselves to the ordinary causes of disease to a degree 
not noted in other persons. 

It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis; and, if that fact cannot indubitably be ascertained, to be 
careful that the statements of the patient are not allowed to bias the 
judgment in pronouncing upon any eruption present; second, suppos- 
ing that such a fact is established by clinical proofs without reserve, 
to decide whether the eruption present is produced by the existing 
syphilis or some other externally or internally operating cause ; and if 
this last be determined, to be careful in eliminating the syphilitic influ- 
ence from its operation. 



SYPHILIS. 735 

Ignored syphilis is usually severe ; but it is without avail that dis- 
orders of a different character are treated by the methods useful in 
syphilis. Thousands are annually thus mistreated who might have 
been spared such a calamity. The frequent occurrence, after a suspi- 
cious exposure, of a balanitis, of an attack of progenital herpes, of 
uninfected excoriations, of blennorrhagic discharges, and even the 
appearance of molluscous tumors, warts, or parasitic cutaneous dis- 
orders upon the genital region, is a source of alarm and of fruitful 
error to the many rather than to the few. 

The diagnostician none the less must ever be on the alert to recog- 
nize the symptoms of the disease in those who least suspect it. Thus, 
married women complaining of a " humor of the blood," men who have 
been "overheated and broken out with a rash," and a long list of 
patients exhibiting upon their persons the symptoms of " salt rheum," 
"tetter," "scrofulous ulcers," and "erysipelas" are those whose speedy 
relief will depend upon the skill of the practitioner in recognizing 
the precise nature of the malady. 

The diagnosis of syphilitic lesions of the skin is a matter of the very 
greatest importance, inasmuch as the health, comfort, mental happiness, 
and domestic relations of thousands of men and women annually depend 
upon it alone. An error in either direction may involve the most 
serious consequences to both physician and patient. He is but poorly 
qualified to discharge the important duties of a general practitioner of 
medicine who has not carefully trained himself to establish the truth 
in these cases, irrespective of the diagnosis of the patient and of all 
others who may have been consulted. 

Treatment. — The syphilodermata are to be treated by topical 
applications intended to hasten their disappearance or involution ; but 
as local manifestations of a constitutional disease, their management is 
largely that which looks to the relief of the latter. 

The treatment of syphilis, in the pages which follow, is described 
in outline, so far as it relates to the relief of cutaneous lesions and of 
the systemic condition. The important modifications of therapy that 
are required in the management of syphilis of the osseous and the 
nervous systems, of the respiratory, gastro-intestinal, and other organs, 
it is scarcely necessary to remark, are fully described in the standard 
treatises specially devoted to this subject. Among them may be named, 
as of American authorship, the works of Taylor, 1 of Morrow, 2 of 
Keyes, 3 of Hyde and Montgomery, 4 of White and Martin, 5 and of 
Bangs and others. 6 Of those more or less recently published abroad 



1 Pathology and Treatment of Venereal Diseases. Philadelphia, 1900. 

2 System of Genito-urinary Diseases, Syphilis, and Dermatology. New York, 1893 
(3 vols.). 

3 Surgical Diseases of the Genito-urinary Organs, including Syphilis. New York, 
1888. 

4 Syphilis and the Venereal Diseases (2d edition). Philadelphia, 1900. 

5 Genito-urinary Surgery and the Venereal Diseases. Philadelphia, 1897. 

6 American Text-book of Genito-urinary Diseases, Syphilis, and Diseases of the 
Skin. Philadelphia, 1898. 



736 NEW-GROWTHS. 

maybe named the standard treatises of Jullien, 1 of Fournier, 2 of Diday 
and Doyon, 3 of Mauriac, 4 of Neumann, 5 and of Lang. 6 

The first and often the most important consideration for the prac- 
titioner who is in face of a syphilitic patient is the care of that patient's 
general health. Simple and natural as it may be to set down such an 
injunction in this connection, its importance rests upon the fact that it 
is too often neglected. Patient and physician respectively are often 
hurried into the precipitate ordering and swallowing of specific drugs 
without regard to other as important details. 

It is well to hand to the patient, at the outset of all treatment for 
syphilis, a slip of paper on which are printed in concise and simple 
terms a set of rules to be observed during the continuance of the dis- 
ease. For physicians who do not take similar precautions it is advisa- 
able to enter rather fully into the explanation of certain details which 
the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the serious 
nature of the disease recognized, since every infected patient has an 
interest in knowing this fact, and its important bearing upon his or her 
relations to the uninfected. To every such patient, with the assurance 
that the disease is often benign and productive of little discomfort and 
in any case is curable, it should be stated that the affection is contagi- 
ous and capable of transmission to sound persons by physical contacts 
of various characters. The patient should be instructed as to the 
nutritious character of the diet he should select, and should be informed 
that an increase in body-weight while subjected to treatment is de- 
cidedly favorable in the matter of prognosis ; that the starving and 
sweating processes so highly esteemed by the charlatan and the advo- 
cate of the virtues of the waters of certain resorts are relics of antiquity, 
as useless in fact as they are frequent sources of peril. 

The bathing of the body is a matter of importance. Hot, Turkish, 
and Russian baths, as a rule, are to be interdicted, inasmuch as they 
tend to invite cutaneous hyperemia, and thus to favor the occurrence 
of eruptions. Cool or tepid baths are to be employed sufficiently often 
for the purpose of cleanliness, and by the sponge rather than by immer- 
sion. I)ry friction daily of the surface of the body may be ordered 
with advantage where the skin is still sound. The teeth, the mouth, 
and the gums require constant care. The use of the tooth-brush with 
cool water twice daily is a matter of importance, and the brushing 
should be preceded for a time, when the gums at the outset are in a 
tender, fungous, or hemorrhagic state, by gentle friction of the teeth 
with the finger, covered by a handkerchief dipped in a weak spirit-and- 
water lotion, to which tincture of cinchona and of myrrh may be added 
in any desired proportion. Tobacco in every form is decidedly inju- 

1 Traite pratique des Maladies veneriennes. Paris, 1886. 

2 Lecons sur la Syphilis, etc. Paris, 1873. La Syph. Hered. tard., 1886. Traite- 
ment de la Syphilis. Paris, 1895. Les Chancres extra-genitaux. Paris, 1897. Traite 
de la Syphilis, tome i. Paris, 1898-99. 

3 Therapeutique des Maladies veneriennes. Paris, 1876. 

4 Lecons sur les Malad. vener. Paris, 1883 and 1895. 

5 Syphilis. Vienna, 1896. 

tt Vorlesung. iiber Pathol, u. Therap. d. Syphilis, Wiesbaden, 1896, 



SYPHILIS. 737 

rious. Often the patient should be sent to a competent dentist for the 
extraction or the filling of carious teeth, and for the removal by the file 
or the dental engine of all sharp, projecting edges. 

Malt liquors, wines, and spirits should be employed solely under the 
explicit direction of the physician. They are exceedingly useful in 
debilitated subjects of a certain class, and need not be prohibited in 
toto to those long habituated to their use. At the same time, an im- 
proper use of these stimulants is in the highest degree harmful. When 
employed at all, they should be restricted rigidly to the dining-table 
and the hours of meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the non-infected. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has proved 
exhausting, the recreation of travel — the claims of all these need at 
times to be urged by the physician. With this the patient should be 
encouraged to free his or her mind from needless anxiety, and to avoid 
particularly the company and conversation of those similarly infected, 
whose opinions are based too often upon ignorance or upon a knowl- 
edge of half-truths. The literature of syphilis, for a similar reason, is 
to be eschewed, as a mass of patients, too many of whom purchase 
treatises on the subject, are able only imperfectly to glean the meaning 
of the authors consulted. 

It should be a rule to urge a married patient to inform the conjugal 
partner frankly of the fact of infection, for the sake of both. When 
this advice is followed much future trouble is avoided, and one of the 
obstacles to a completely favorable issue is at once set aside. Instances 
occur in which disruption of the conjugal bond results from infec- 
tion of one, but usually of both parties ; it is a striking argument, 
however, in favor of the policy here urged, that cases are rare in 
which a frank and honorable confession has been followed by sepa- 
ration. It may be added that in the " confessed " cases there is rarely 
subsequent infection of the innocent. The larger number of married 
patients are husbands. Recently infected young adults who have 
contracted a marriage-engagement should invariably claim release from 
such a tie for the sake of all concerned. The syphilitic nurse must at 
once be taken from the sound nursling, and the child with hereditary 
syphilis must be suckled only by its mother, who, according to Colles's 
law, the exceptions to which are so few as to prove the rule, always 
enjoys immunity against the diseased mouth of her own child. 

Respecting the medicaments employed in the treatment of syphilis, 
there is no routine plan which in every case can advantageously be 
followed. In no respect do physicians so differ from each other, 
judged by the standard of professional skill, as in their ability to use 
a single remedy with success. He who has the largest armamentarium 
is not always either the best equipped or the most successful. Mercury, 
iodine, iron, and quinine are the great remedial agents in syphilis, but 
they may vainly be used by one man in the long effort to accomplish 
that which another speedily and brilliantly achieves by the use of the 
same remedies employed with greater skill. 

Of the other substances vaunted as either advantageous or specific 

47 



738 NEW-GROWTHS. 

in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guaiacum, tayuya, mezereon, and the long list of other vegetable prep- 
arations whose virtues have thus been extolled, are for the most part 
as harmless in themselves as they are ineffectual for the relief of the 
malady. 

Before proceeding, however, to assume the responsibility of directing 
a course of treatment for syphilis with remedies of acknowledged value, 
the physician will do well to remember that no two cases of the disease 
are precisely alike, and that there is the widest range between the most 
benignant forms encountered in private practice and the malignant 
cases seen in hospital-wards. Some forms of the malady are so mild 
as to constitute merely an inconvenience ; others are so severe as to 
destroy life. It is an axiom in venereal disease that more patients per- 
ish annually from blennorrhagia and its results than from syphilis. 
There could be no greater error than to treat by a uniform method any 
disease exhibiting so wide a variation in severity. 

Mercury, after the assaults upon it of generations of men of admitted 
wisdom and candor, stands to-day unrivalled as a remedy for the relief 
particularly of those stages of syphilis in which the skin is involved. 
Administered with skill, it can be employed for years with advantage 
to the syphilitic patient, who, during a well-regulated mercurial course, 
should gain in weight, improve in vigor, and exhibit a healthy 
color of the skin. No competent physician to-day employs mercury 
in such a manner as to induce salivation or other toxic consequences. 
Such effects of the remedy result from carelessness or ignorance. In 
every discussion of the merits of mercury in syphilis both physicians 
and patients have been guilty of the ignorance or the folly of ascribing 
to the remedy the disastrous effect of the disease. 

Mercury may be given by the mouth, by inunction, by subcutaneous 
injection, or externally by the aid of the vapor-bath. The most popular 
method, and that productive of least inconvenience to all concerned, is 
the method by ingestion. 

Ingestion. — In this mode of treating syphilis the mild chloride, 
bichloride, bicyanide, or blue mass, of mercury may be employed effec- 
tively. These preparations, however, are rather less adapted than others 
for continued employment during long periods of time, and are open to 
the objection of either readily undergoing rearrangement into more 
stable compounds of the metal, or of producing undesirable irritative 
effects. With the protiodide and the biniodide an impression can be 
produced upon the system that can readily be proportioned to the 
exigencies arising in every case, which can be sustained during that 
" chronic medication " which Fournier declares to be requisite in every 
chronic disease, and which can be exerted without fear of immediate or 
of remote deleterious consequences. 

Treatment of syphilis by the mercurial selected for use should, as a 
rule, be begun only at the moment of evolution of constitutional symp- 
toms. The initial sclerosis of the disease is amenable to the action of 
the metal to a remarkable extent, but in a large proportion of cases the 
chancre will cicatrize, when in an ulcerative stage, without having re- 



SYPHILIS. 739 

course to general medication. Early mercurial medication may well be 
reserved for such primary lesions as are threatening in symptoms, and 
for such individuals as require or demand speedy cicatrization of their 
chancres, as, for example, those about to travel beyond the reach of med- 
ical assistance. Personal experience fully confirms the wisdom of the 
teaching which reserves specific medication until the second period of 
incubation has passed. No local or general treatment can avert either 
a mild or a severe explosion of symptoms after that period is completed. 
In experiments made to determine this question of delay there has 
been either the production of strikingly irritative effects, such as a 
marked relapse, or unusual increase in the volume of the initial sclerosis 
immediately before the evolution of the first syphilodermata, or a dis- 
tinct obstinacy in the latter to the action of the medicament employed. 

In the early stages of syphilis in adults the mercurous iodide may 
be named as one of the most trustworthy preparations. Of all classes 
of adult patients, including strong men and adult women, there are 
scarcely 2 per cent, who cannot take it, if the dose be proportioned to 
individual susceptibility. It is usually administered in pill or in tablet 
form in doses of 1 (0.01), -J- (0.013), \ (0.016), or \ (0.022) of a grain, 
three times daily, combined with the extract of gentian. The dose 
may be increased gradually according to the necessities of the case, 
from \ (0.032) to 3 (0.207), and even 4 (0.266) grains in the twenty- 
four hours. Many of the gelatin-coated pellets found in the market 
contain accurately divided doses of the salt. The sugar-coated pills 
of Gamier and Lamoureux, containing each 1 centigramme of the 
protiodide, are efficient and largely employed. 

Beginning with a minimum dose, this remedy is to be steadily 
exhibited, and the daily quantity consumed to be gradually increased 
until the degree of tolerance of which the patient is capable has been 
ascertained. Should the stools become frequent, pain be excited, or a 
slight effect produced upon the mouth, as indicated by a metallic taste, 
moderate increase in the quantity of saliva, or any noticeable degree of 
tenderness of the gums, the dosage is to be gradually diminished until 
these symptoms disappear. Often the withdrawal of \ (0.033) or \ 
(0.013) of a grain daily will suffice to enable the patient to tolerate the 
quantity thus diminished. The medication is to be faithfully continued 
until the object in view is obtained, viz., relief of all symptoms of the 
disease. 

In Keyes's so-called "tonic treatment of syphilis" the dosage is 
increased only on each third or fourth day, until irritative effects are 
produced, when, after an interval of two days, the quantity taken at 
the time of the production of such effects is reduced from one-half to 
one-third. This reduced quantity is termed the " tonic dose," and is 
thereafter continued throughout the treatment in " nearly all conditions 
of health or disease." l 

No case of syphilis can be said to have been treated properly in 

which iron has not been given for at least a part of the time during 

which the patient was under observation. Ferric citrate with quinine 

is an excellent preparation administered at the meal-hours, in a small 

1 Amer. Jour. Med. Sci. 4 1876> xcvii., p. 17 ; Pbila. Med. Times,, 1882, xii., p. 337, 



740 NEW-GROWTHS. 

quantity of sound sherry wine ; or ferrous iodide may'be employed in 
syrup, or in pills made after the formula of Blancard, or in Vallet's 
mass. In some cases tincture of ferric chloride may be employed, but 
the physician should be careful about ordering an acid preparation 
during a mercurial course. There is no form of anaemia which responds 
more promptly to the chalybeates than does that produced by the syph- 
ilitic virus. 

The mercuric iodide may be substituted for the mercurous iodide 
when, for any reason, it is thought desirable, beginning with a minimum 
dose of -^ grain (0.001), and increasing this gradually to -fa (0.0016), 
or rarely to -^ (0.0033), either in pill or in solution. The average 
dose of -£q (0.0016) of a grain in pill-form, administered three times 
daily, soon after eating, is tolerated by the majority of all patients of 
both sexes without consciousness of unpleasant effects. 

Calomel may be administered in 1 or 2 grain doses (0.066-0.133) 
three times daily, in combination with an opiate to prevent its action 
on the bowels, or in y 1 ^- grain dose (0.0066) every hour. Small doses 
of blue mass or of gray powder may also be employed. The gray 
powder is most suitable for children and infants, but since the discovery 
in the drug of the corrosive chloride, either as of early or of late 
chemical production, the gray powder is esteemed less. The decimal 
trituration of calomel with sugar of milk is a far more suitable com- 
pound. Corrosive sublimate, in doses of from -^ (0.0033) to -fa (0.005) 
of a grain is exhibited in pill-form or in solution, and probably is em- 
ployed more generally in the treatment of syphilis than any other mer- 
curial salt. The objections to its use are suggested above. Though 
constantly employed in public charities, where it is furnished as a cheap 
and a convenient substitute for the more elegant preparations in the 
market, it is ordered much less frequently for syphilitic patients in 
private practice. When given in solution it produces a disagreeable 
metallic taste in the mouth that some patients can perceive after the 
lapse of hours. 

With many physicians of experience it is customary to employ 
opium, either alone or in connection with the use of mercury, for the 
relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent the 
cathartic action of the metal upon the bowels, and again because it is 
supposed to possess some power of arrest over the destructive action 
of the disease. It should not, as a rule, be exhibited when by reducing 
the mercurial or exchanging the latter for a ferruginous dose the same 
result can be reached. Few syphilitic patients are in the end brought 
to the desired termination of the disorder by the use of a remedy which 
interferes with assimilation and digestion. Temporary advantage often 
is gained by its employment, but this may be more than counter- 
acted by its ultimate effect upon the gastro-intestinal tract. 

Inunction. — Mercury is introduced satisfactorily by the method 
of inunction. The metal when thus employed is absorbed readily by 
the system, and its therapeutic value is great. Inunction should be 
employed in every case which admits of it, since the gastro-intestinal 
tract thus is left undisturbed, and, further, the dose of any needed 



SYPHILIS. 741 

chalybeate or of potassium iodide by the mouth can be regulated with- 
out increasing or diminishing the quantity of mercury in daily use. 
Mercurial ointment compounded with lanolin is used best for this pur- 
pose. Cleanly but far less efficient substitutes for it are provided in the 
oleate of mercury in the strength of 10, 15, or 20 per cent., and in the 
vasogen capsules. From J to 1 drachm (2.-4.) of either the ointment, 
the vasogen compound, or the oleate may be rubbed into the skin at 
night before retiring, and the part selected for inunction be cleansed by 
washing in the morning. Unna for this purpose praises the mercury- 
salve soaps. All these preparations, if continually applied to a single 
portion of the skin, are liable to produce a mild local dermatitis, hence 
it is wise to select on successive evenings a fresh portion of integument 
for the local application, preferably that where the epidermis is rela- 
tively thin, as, for example, the flexor aspects of the joints. The 
patient can thus upon one evening anoint the inner faces of the thighs ; 
upon the next, the sides of the chest ; upon another, the loins, etc., 
taking care to avoid surfaces where an induced eczema is likely to prove 
especially annoying, such as the scrotum, the axillae, and the groins. 
The ointment in some cases may be well rubbed into the soles of the 
feet previously soaked in warm water, after which the socks or stock- 
ings may be drawn over the feet for the night. In the case of infants 
the inunction is well performed by the natural movements of the child, 
if a flannel swathing-band previously smeared with the salve be 
wrapped about its belly, so that the mercurial preparation is kept in 
contact with the skin. Should local irritative effects be produced, these 
subside rapidly, as a rule, after a warm alkaline ablution followed with 
a bland dusting-powder. Subsequently or even before such accident in 
the case of infants or of patients having unusually sensitive skins the 
mercurial salve may be mixed with equal parts of lanolin, lard, or 
olive-oil. As some patients become disgusted with this routine, it is 
well at the onset to flavor the substance selected for inunction with 
lavender, rosemary, or bergamot. 

Too little attention has been attracted to the treatment of syphilis by 
mercurial inunction. With this fact in view the preceding paragraphs 
which describe the use of mercury by the mouth are to be understood 
as related in all cases to the employment of the metal by the skin. It 
is well to order inunction in all practicable cases ; to save the stomach 
as much as possible ; to continue with the mercurial ointment nightly, 
weekly, or less frequently, so long as there is a possibility of relapse ; and 
to adjust carefully the quantity employed to the exigencies of the case. 
In this manner patients may be relieved of all symptoms of the dis- 
ease who have not during their treatment swallowed a dose of mercury, 
and the permanency of whose relief may be tested during years of sub- 
sequent observation. 

Fumigation. — One of the most effective methods of administering 
mercury is by fumigation in the vapor-bath. It is employed by many 
experts as the sole means of exhibiting the mercurial selected for 
use, but it is, for the average patient, too inconvenient for continuous 
employment. It should regularly be ordered, first, in all cases in 
which the earliest syphilodermata are intense, generalized, and partic- 



742 NEW-GROWTHS. 

ularly conspicuous upon the face ; second, in all obstinate cases in which 
the patients are not women nor cachectic subjects of either sex ; third, 
at the outset of treatment of many " ignored " cases in which the syph- 
ilodermata, either more or less generalized, have proceeded to uninter- 
rupted evolution ; fourth, in the severe cases of patients coming from 
the country to the city, who are able to remain but a brief time 
within reach of advantages offered in metropolitan centres. From \ 
to 1 drachm (2.-4.) of calomel, metallic mercury, the bisulphuret, the 
black oxide, or hydrargyrum cum creta may be employed for each 
bath. It is common to order 1 scruple to 1 drachm (1.-4.) each of 
calomel and cinnabar. The patient is stripped of his clothing and 
seated in a chair, the patient and chair being completely enveloped in 
blankets, which are closely fastened at the neck of the bather. Beneath 
the chair is an alcohol lamp, surmounted by a metallic vessel containing 
water in ebullition, the hot vapor of which in a few moments induces 
copious perspiration. When this result is obtained the lamp is brought 
beneath a metal plate containing the substance to be volatilized. The 
patient remains exposed to the vapor about ten minutes after this proc- 
ess of sublimation is finished, and retires at once to bed without 
cleansing the skin, the fumigation preferably being conducted before 
the hours of sleep. In the morning a bath may be taken for the pur- 
pose of cleanliness. It is convenient in the generation of the vapor 
in this way to make use of the Schering or other fumigating lamp, 
but the materials requisite for the production of all desired effects, 
with the exception of the alcohol lamp and the drug, can be procured 
of any skilful tinsmith. In the city male patients are often sent to 
bath-houses, where the fumigation is conducted in the daytime ; and, 
as a consequence, they rarely experience unpleasant effects, such as are 
popularly associated with " taking cold " after exposure to the action 
of mercury. In most of these establishments provision is made that 
the head also can be exposed to the mercurial fumes, respiration 
being conducted through a tube in connection with pure air, a provision 
useful in certain cases of emergency ; and only " emergency cases " 
should be required to resort to fumigation of the head. 

Subcutaneous Injection. — The treatment of syphilis by mercurial 
injection has been extended largely since its acceptance as a scientific 
procedure. In common with some of the other methods employed, 
injection provides for the exclusion of the medicament from the gastro- 
intestinal tract, and accomplishes the desired effect with a minimum and 
exactly mensurable dosage. The objections to its systematic employ- 
ment outside of hospitals are chiefly the need of a physician or an 
expert to administer the dose. The injection of mercury into the deep 
muscular tissue (the gluteus in its thickest part with the muscle wholly 
relaxed ; the trapezius above the upper scapular angle with equal lack 
of tension), as well as when practised more strictly hypodermatically, 
requires all antiseptic precautions both as to the point where the needle 
is inserted and as to the instrument itself. These injections occasion- 
ally have proved fatal (calomel, gray oil) ; grave mischief has followed 
in one or two instances from visceral troubles ; and the attacks of syn- 
cope which result in certain cases from these injections have presented 
alarming and even dangerous features. 



SYPHILIS. 743 

This method, which first Avas popularized by Lewin, 1 is efficient 
and speedy, but will probably always find largest favor in the treat- 
ment of hospital patients, who are completely subject to the orders 
of their medical attendant. At the site of the injection, too, not 
rarely abscesses have formed. Corrosive sublimate, -^ (0.005) or 
l grain (0.008), dissolved in 10 or 15 minims of distilled water 
may be injected at a time, the operation being repeated upon about 
twenty occasions. Bamberger, of Vienna, reported favorable results 
after the injection of an albuminate or a peptone of mercury, thus 
attempting to avoid the danger of localized abscesses, and insuring 
speedy absorption of the metal. All formulae, however, proposed for 
preparation of solutions of this character have proved imperfect, both 
in consequence of failure to obtain a pure metallic albuminate, and 
also from lack of permanency in the solution. Staub's formula, the 
result of experiments made by Hepp, 2 may be taken as a sample of the 
rest: 

R Hydrarg. chlorid. corros., gr. xviij ; 1(20 

Ammon. chlorid., gr. xviij ; 1 20 

Sod. chlorid., 3j ; 4 

Aq. dest., fjiv; 120 M. 

Dissolve, filter, and add the white of one egg in distilled water sufficient 
to make §iv(120.); 15 minims of the solution contain about ^ 
grain (0.005) of the sublimate. 

Other preparations employed for hypodermatic injection are as 
follows : 

Insoluble salts of mercury. Here are included calomel in an aver- 
age dose of 1 grain (.066) suspended in vaselin-oil, salt and water, or 
mucilage and water; metallic mercury, from 6 to 30 grains (0.40-2.); 
oleum cinereum, mercury with liquid vaselin or lanolin, 20 to 50 per 
cent., 0.05 to 0.1 at each injection; and the yellow and the black oxides 
of mercury, corrosive sublimate, mercuric cyanide, and combinations of 
these with potassium iodide and other salts. 

The so-called "antiseptic group" includes salicylate of mercury. 
A Pravaz syringeful is injected every third day in the gluteal region 
beneath the muscular fasciae, of the following : 



R 



Hydrarg. salicylat., 


gr. xv-xxiv ; 


11- 


Mucil. acac, 


gr. viij ; 


533 


Aq. dest., 


f^vss; 


165[ 



M. 



In this group are also included carbolate of mercury; thymolate 
(10 per cent, suspensions in fluid paraffin); and the benzoate associated 
with sodium chloride, 2 parts, and cocaine hydrochlorate, 1 part, in 500 
of water. 

The amide group includes mercuric formamidate, 1 per cent, solu- 

1 Die Behandlung der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; 
also translated by Proegler and Gale, Phila., 1872. 

2 Traitement de la Syph. par les Inject, hypoderm. de Sublime. These de Paris, 
1872. 



744 NEW-GROWTHS. 

tion ; glycocoll of mercury, alaninate of mercury, and succinamide of 
mercury, the last two in 1 per cent, solutions. 

Beside these mercurial preparations, potassium iodide and iodoform 
have subcutaneously been injected in a few instances, it is claimed 
with advantage. 

Intravenous injections of mercury in syphilis have been practised, 
but, according to Marshall, 1 have not been shown to possess any ad- 
vantages over other methods employed. Chopping, 2 however, had sat- 
isfactory results in twenty-three days after introduction into artificially 
distended veins of 20 minims of a 1 per cent, solution of mercurous 
cyanide. 

- Ptyalism, stomatitis, fetor of the breath, or a fungous condition of 
the gums with in appetence and other characteristic symptoms of the 
ill effects of mercury, including all grades of gastro-intestinal disturb- 
ance, are seen rarely in modern practice, and they should never 
occur in a properly regulated mercurial course. When they are 
produced, the tongue projected from the mouth is usually tumid, and 
exhibits at its lateral borders the imprints of the inner faces of the 
molar teeth. Its surface is also covered in various degrees with a thin, 
dirty-grayish coat ; and the odor of the breath is peculiarly offensive, 
being often noticeable at a distance of several feet from the patient. 
In such cases the food should be liquid and nutritious, both hot and 
cold drinks should scrupulously be avoided, and the mouth frequently 
be cleansed with washes containing dilute liquor sodse chlorinate, potas- 
sium chlorate, borolyptol, or a very weak solution of carbolic acid. In 
particularly severe cases, potassium chlorate may be employed to the 
extent of 1 drachm (4.) daily. The compressed tablets of this salt, 
each containing 5 grains (0.33), may be slowly dissolved in the mouth. 
The mercurial is to be suspended in all cases, and iced water is to be 
interdicted, gangrene having followed its use in a few cases. In 
milder forms tincture of myrrh and of cinchona, diluted with sweetened 
water, or honey and water, will be sufficient for local medication of 
the mouth.. 

Iodine is employed chiefly in syphilis in the salts of potassium and 
sodium. The iodides of ammonium, rubidium, and strontium are less 
effective. Iodine possesses some value, without question, in every stage of 
syphilis, and is, therefore, indiscriminately used by many practitioners. 
Its value, however, in so-called " late secondary " and " tertiary 
stages " is incontestably greater than in the earlier lesions of the dis- 
ease, and its use should largely be restricted to the particular periods 
in which these manifestations appear. Every prudent physician will 
hesitate before ordering for a disease exhibiting cutaneous lesions a 
remedy which will positively produce such lesions in the majority of 
all patients ingesting it. In this connection the reader will do well to 
consult the chapter on Dermatitis Medicamentosa, in which the various 
eruptions produced by this drug are recorded. Thoughtful men are 
beginning to inquire, in the light of the present knowledge upon this 
subject, to what extent the syphilodermata have in the past been 

1 Lancet, 1899, i., p. 618. 

2 Ibid., p. 432. 



SYPHILIS. 745 

aggravated or obscured by this remedy. He would indeed be bold 
who should attempt to prove that the medicamentous eruptions thus 
excited have not, in the past, figured largely in the catalogue of the 
syphilodermata. 

The value of the iodine compounds, nevertheless, properly adjusted 
to the age and other conditions of the disease, is incontestable. Whether 
given alone or by the so-called "mixed" treatment in combination 
with mercury, or administered internally while a mercurial is intro- 
duced by the skin, or exhibited by alternation with the metal, in each 
these compounds find a special value, and may simply be indispensable. 
Potassium iodide may be given in doses of from 5 grains (0.33) to 1-2 
drachms (4.-8.), well diluted with water (a gobletful preferably), three 
or four times daily one hour after eating. The larger doses should 
invariably be reached gradually ; they should never be employed except 
by special order of the physician, and when the patient is within easy 
reach of the latter ; and they should always be ordered with the under- 
standing that the patient shall diminish or suspend treatment in case 
of unpleasant results. When the remedy produces gastric distress, it is 
administered often in connection with pepsine, pancreatine, or taka- 
diastase. Often the dose is tolerated well when given in a glassful 
of milk. 

Symptoms of iodism, other than the production of cutaneous lesions, 
such as coryza, oedema of the eyelids, abdominal tension and tenderness, 
and faucial irritation, are likely to be the result of the first few doses 
of iodine ingested, and these symptoms often bear no relation to the 
size of the dose. In certain cases, 1 or 2 grains (0.066-0.133) will be 
sufficient to produce the most disagreeable effects, which, if they occur 
before the remedy be suspended, may not return with even the largest 
doses. In a few cases potassium iodide produces violent toxic effects 
in any dose, owing to exceptional idiosyncrasy. Both ammonium 
chloride and ammonium carbonate are recommended for use in combi- 
nation with potassium iodide, as increasing its efficiency. Sodium, 
ammonium, and lithium iodides possess also, without question, some 
influence over the disease, but they are for most cases less efficacious 
than the potassium salt. Of the three iodides named, lithium iodide 
is apparently most prompt in its effects. 

Potassium iodide is employed frequently in the well-known " sirop 
de Gibert," which though first popularized in the Saint-Louis Hospital, 
in Paris, has since been employed extensively in the United States. It 
has slightly been modified to suit the varying tastes of many surgeons. 
It is ordered in the following formula : 



B Hydrargyri biniodid., gr. ss-ij ; 

Potass, iodid., 3ij-viij ; 8-30 

Gentian, syrup, (vel ) 

syrup, glycyrrkiz.), [■ aa f ^ij ; aa 60 

Aq. dest., ) 

Dose. A tablespoonful in water, after eating. 



033-0.13 



M. 



The syrup of licorice disguises the taste of the drug better than most 
of the other syrups used. With the dosage carefully regulated, a few 
drops (1 to 15) may be administered with advantage to children. 



746 NEW-GROWTHS. 

The following are indications for the use of potassium iodide either 
alone or by the so-called " mixed " method in the treatment of syphilo- 
dermata : the occurrence (1) of tubercular, gummatous, or ulcerative 
lesions ; (2) of formidable, nervous, visceral, or other non-cutaneous 
symptoms with early or late, mild or severe syphilodermata, as, for 
example, grave ulcerations of the velum or the fauces with a sym- 
metrical macular eruption, or coincidence of a generalized pustular or a 
papular syphiloderm with hemiplegic, aphasic, ocular, or renal compli- 
cations ; (3) of manifestations which either assume the so-called " gal- 
loping " type, being succeeded rapidly by more and more formidable 
symptoms, or which exhibit the capriciousness of the disease in a 
reversal of the usual sequence of evolution, as, for example, when 
symptoms commonly described as " late " phenomena occur within a few 
weeks after infection and are followed by the early symmetrical rashes ; 
(4) of early or late symptoms occurring in cachectic, strumous, or other- 
wise debilitated patients. Mercury is assuredly not a tonic in tubercu- 
losis commingled with syphilis. 

Klingm tiller 1 advocates for appropriate cases the employment of 
iodipin, an organic combination of iodine and sesame oil. It is used 
both internally and by subcutaneous injection. We have found it of 
value in obstinate cutaneous lesions. 

The local treatment of the initial sclerosis of syphilis by complete 
excision, lauded by Auspitz, has been practised (since the date of his 
paper in 1879) by Kolliker, Zeissl, Leloir, Chadzynski, Mauriac, and 
others. 2 The result has proved conclusively that such operative inter- 
ference furnishes no bar to constitutional infection. Simultaneous 
extirpation of all lymphatic glands in the vicinity of an initial sclerosis, 
with ablation of the latter and a mass of tissue about it, have repeatedly 
proved unavailing to prevent the occurrence of systemic infection. 
Chancres should not be destroyed by caustic agents of any character, 
as the caustics are liable to induce either irritative or inflammatory 
effects which may be followed by denser induration. Ointments, as a 
rule, are also objectionable, exception being made in the case of hemor- 
rhagic lesions when the removal of an adherent dressing is followed by 
unpleasant consequences. Cleanliness with soap and water is of chief 
importance. There are few better local applications at this period of 
the disease than painting with a saturated solution in water of pyok- 
tanin-blue. The parts may then be dusted with a dry powder, such as 
europhen, iodol, zinc stearate, calomel, hydronaphtol, or boric acid; 
or be dressed with a piece of soft lint, saturated in pure or dilute lotio 
nigra, or, even better, a spirit-lotion containing tannin and carbolic or 
boric acid. Opiated washes or iodoform (which is an anaesthetic for 
many ulcerative surfaces) may be requisite in painful and ulcerative 
lesions. 

When a primary venereal sore of any character (the initial scle- 
rosis of syphilis or the chancroid) becomes phagedenic or gangrenous, 
or, even in the absence of both these calamities, extends rapidly 
in depth or superficial area, cauterization should not be practised. 

1 Berlin, klin. Wchnschrft., 1899, xxxvi., p. 540. 

3 See Keyes' later communication on this subject, loc. cit. 



SYPHILIS. 747 

The most effectual treatment of these complications in the genital 
region is by the employment of the continuous hot water-bath, aided 
by antisepsis. The patient remains seated in the bath (the water being 
of the temperature most grateful to the affected surface and with great 
care maintained at that degree of heat) throughout the day, or, in 
formidable emergencies, if carefully watched, by day and night. The 
bath is left by the patient only for the purpose of evacuating the bladder 
or the rectum. Granulation and repair gradually ensue. Whenever 
the patient leaves the water the parts are dusted with iodoform or with 
iodol. By this invaluable means, in both hospital and private prac- 
tice, cicatrization of extensive ulcers which extend from the genital to 
the pubic region may be secured. 

Local treatment of the syphilodermata may be demanded either by 
reason of their appearance on exposed surfaces, as on the face and the 
hands, or by reason of their obstinacy or threatening character, as 
when they are rapidly ulcerating. Macular and papular lesions of 
the face may be treated by local applications of mercury : 5 per cent, 
oleate ; mercurial ointment, 1 to 2 drachms (4.-8.) to the ounce (30.) 
of cold-cream salve or of vaselin; red oxide, from 2 to 4 grains (0.133- 
0.266) to the ounce (30.) ; or ammonium chloride, \ to 1 scruple (0.666- 
1.33) to the ounce (30.) of ointment. Lotions of bichloride, 1 to 2 
grains (0.066-0.133) to the ounce (30.) of cologne, are also efficient. 
These preparations are more effective if applied at night, and left 
upon the lesions during the hours of sleep, and each is preceded best 
by hot bathing of the surface for several minutes, as in the preparatory 
treatment of acne papulosa. The sulphur preparations employed for 
the relief of that disease will at times be found useful also in the 
local treatment of the syphilodermata. 

Hot ablution is particularly useful in the treatment of the scaling 
and frequently fissured lesions of the palms and soles, the pain of 
the local symptoms in severe cases being greatly alleviated by this 
treatment. After the epidermis in these parts has been well macerated, 
the hands or the feet should thoroughly be dried, and the mercurial, 
tarry, or other salve be well rubbed in. The medicated mulls and 
plasters are here of value. A glove or a stocking should then be 
drawn over the part. 

Secreting condylomata, flat papules, vegetations, etc., also require 
bathing with soap and water, especially when situated at the mucous 
outlets of the body or on the scalp. When the secretion is offensive in 
odor, formalin, boric or carbolic acid, thymol, or chlorinated soda should 
be added to the lotion. Cleanliness, indeed, is more essential to the 
syphilitic patient, man or woman, than to the healthy. After the 
cleansing or disinfecting ablution the parts may require pencilling 
with the crayon or with solutions of silver nitrate, 10 to 20 grains 
to the ounce (0.50-1.5), and may be dressed with a powder, such as 
dry calomel, europhen, iodoform, iodol, hydro-naphtol, bismuth sub- 
nitrate, zinc oxide, sodium salicylate, or starch. Vegetating lesions 
of these regions may require also pencilling with a crayon of silver 
nitrate. Ointments/ as containing grease, are decidedly objectionable 
local applications. 



748 NEW-GROWTHS. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be removed 
either by the oil and soap-and-water treatment, or with a dermal 
curette, after which removal the underlying ulcers should be cleansed 
thoroughly, pencilled with silver nitrate, filled with powdered boric 
acid, iodoform, iodol, or calomel, or touched with a 5 to 20 per cent, 
solution of carbolic acid, and then be dressed with a dilute ointment of 
mercuric nitrate, 1 to 2 drachms (4.-8.) to the ounce (30.). Large 
syphilitic ulcers are often encountered on the surface of the lower ex- 
tremities, and in this situation elastic compression by a rubber bandage 
will greatly accelerate their cicatrization. 

Ointments of ammoniated mercury, blue ointment, compound iodine 
ointment, and those containing the yellow oxide are useful in many 
cases. The mercurial, salicylated, zinc-oxide, and other plasters often 
are required for infiltrations. 

The syphilodermata are in general amenable to the action of the 
mercurial vapor-bath, which exerts upon them both a local and a con- 
stitutional influence. Those affecting the face are benefited thus by 
exposure to the metallic vapor in the " head-piece " arrangement 
already described. The patient also may avail himself less comforta- 
bly of the same local treatment by holding the breath and exposing the 
head and face for a few minutes at a time to the fumes of the mercury 
beneath the blanket, in the plan described as practicable at the bedside. 

The syphilodermata, if treated locally by the measures described as 
useful in non-syphilitic cutaneous affections of similar type, will com- 
monly proceed to a satisfactory involution if the general treatment be 
skilfully ordered. 

The local treatment of syphilitic lesions of the mucous surfaces is 
both hygienic and medicinal. Catarrhal conditions of adjacent mucous 
surfaces (vagina, nasal cavity) require attention. The parts should 
be kept free from all irritation (tobacco in all forms, iced and hot 
articles of food and drink, condiments, acetous and alcoholic fluids 
in the mouth ; coitus and irritating injections of vulva ; napkins that 
have been soiled over the anogenital regions of infants). Locally, the 
silver-nitrate crayon, used as a pencil, is effective in the management 
of moist patches, applied once daily or every second or third day. 
Occasionally stronger caustics are required, such as mercuric nitrate 
or nitric acid. Mouth-washes containing potassium chlorate, myrrh, 
and honey; 15 to 20 drops in water of Bellamy's iodized phenol; 
borolyptol ; very dilute lotions of tincture of ferric chloride ; or dilute 
muriatic acid, a teaspoonful to a pint of sweetened water ; and carbo- 
lated Avashes, are required in different cases. In very great soreness 
and tenderness of the mouth only the blandest applications are tolerated, 
such as thin flaxseed-tea, oatmeal-gruel as a wash, and gum-acacia 
water. A few formulae are appended : 



R Potass, chlorat., 
Mel. despumat., 
Myrrh, tinct., 
Aq. dest., 



S; 


4 


a 5ss; 


15 


id 3vj ; 


ad 180 



M. 



Sig. A teaspoonful in water as a wash for the mouth and throat. 



SYPHILIS. 749 



R Acid carbolic, Z j ; 4 

a"'" } ** 33S; 

Spts. vin. rectif., 3ij ; 8 

Aq. dest., ad f gj ; ad 30 



M. 



Sig. Fifteen to twenty drops as a lotion in water, for the mouth. 

R Potass, chlorat., 3j 4! 

Aq. menth. piperit., aa ^yj ; aa ISOl M. 

Sig. Gargle and wash for the mouth ; to be used slightly diluted. 

The internal management of these cases is that demanded by the 
general condition of the system and the stage of the disease, as ex- 
plained in the concluding pages of this section. 

The treatment of inherited is mainly that of acquired syphilis 
with such modifications as are required by the tender age of the sub- 
ject of the disease and by the special characters of the eruptive and 
other symptoms in the infant and child. The mother who is demon- 
strably the subject of the disease requires antisyphilitic treatment during 
any pregnancy where there is possibility of taint of the product of con- 
ception, irrespective of the presence or absence of maternal symptoms ; 
this is especially important in pregnancies succeeding those terminating 
either in abortion or the birth of a syphilitic child. The infant born of 
a syphilitic mother or luetic parents should be spared specific medica- 
tion until evidences of infection are presented, seeing that in some cases 
the foetus and newborn infant escape even when lues is made probable 
by the antecedents of the progenitors. The syphilitic child when the 
disease is inherited should be kept at the breast of the mother and not 
be suckled by any other woman. All syphilitic infants require special 
provision for their nutrition : cod-liver oil generally is indicated. 
Inunction is to be practised by anointing the swathing-band with a 
strong or modified mercurial salve, the motions of the child being in gen- 
eral sufficient to insure a proper medication by introduction of the 
medicament. As the skin of the abdominal surface in these young 
patients is generally sensitive, care should be taken to suspend the ap- 
plication of the unguent and to apply a dusting-powder until any result- 
ing dermatitis is relieved. 

Internally, calomel or the gray powder, ^ of a grain to 1 grain 
(0.006 to 0.06), may be applied to the tongue after trituration with the 
sugar of milk. The stronger homoeopathic triturations are useful for 
this purpose. We rarely employ the bichloride of mercury in infants, 
as the other preparations of the metal are commonly efficient and 
better tolerated. The salts of iodine are less valuable in inherited than 
in acquired syphilis, but when indicated the potassium salt may be given 
in doses of from -^ to 2 or 4 grains (0.006 to 0.133 or 0.25), admin- 
istered in solution three times daily or oftener when required. Iron is 
indicated generally, and in particular the iodide of iron, which may be 
given in the form of syrup 2 to 5 drops in solutions. The dosage is to 
be varied with the age and vigor of the child. Lesions of the mucous sur- 
faces (mouth, anus, nares) require special hygienic care, and the use of 
lotions of boric acid, formalin, chlorinated soda, and in especial soap and 



750 NEW-GROWTHS. 

water are needed. These should be followed often, particularly about 
the ano-genital region, with the application of dusting-powders. The 
eruptive symptoms in inherited syphilis are to be treated like those in 
the acquired disease, due care being taken to protect the tender skin from 
irritation. The tars and stronger mercurial salves should not be em- 
ployed over the skins of very young infants. 

Prognosis. — The prognosis of syphilis is in general favorable, pop- 
ular opinion on the subject being at variance with fact. Benignant 
syphilis may disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. The 
element of treatment, both as to its character and the period of its con- 
tinuance, enters more largely into the estimate upon which a prognosis 
rests than it does in most other disorders exhibiting cutaneous symp- 
toms. Syphilis untreated, whether because of failure to recognize its 
character, or of ignorance, poverty, neglect, or dissipation, is usually 
grave. The same may be said of syphilis occurring in strumous, tuber- 
culous, and cachectic subjects, and in those enfeebled by age, by other 
diseases, by chronic alcoholism, or by sexual excesses. Hereditary 
syphilis is by far the gravest form, not merely because of the tender 
age of its victims, but also because they, at the earliest period of their 
lives, are burdened with a disease which may first attack organs essen- 
tial to life. 

The majority of adult white patients, with hygienic environment, 
sooner or later recover from the acquired disease, marry, and beget in 
the end sound children. 

CHANCROID. 

This term has been adopted generally in America and England for 
the purpose of designating the virulent, local, contagious ulcer of the 
genitals, designated also as the " simple," the " soft," or the " non- 
infecting " chancre, the chancrelle of French authors. Chancroid has 
no relation to syphilis, nor to the neoplasmata with which syphilis is 
commonly classified. As it is, however, a disease with which the initial 
sclerosis of syphilis may be confounded, and is also not merely a venereal 
lesion, but one which may be encountered upon the skin as well as 
upon mucous surfaces, it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the lesions 
of vaccinia or of herpes zoster. They are thus stamped with special 
and readily recognized characteristics, differing in this respect from 
the various modes in which the first lesion of syphilis may declare its 
nature. The virus, for such it must be termed, of the disease is one 
sui generis, and derived exclusively from lesions of like character. This 
virus, which is contained in a purulent secretion, is capable of trans- 
mission by inoculation and auto-inoculation. After such successful 
inoculation there is no period of incubation. The results of experi- 
mental generation of the virus in human subjects indicate that the 
pathological process which it awakens can be determined within twenty- 
four hours after its introduction within the skin. At times, after acci- 
dental infection, eight and ten days elapse before the lesion of the dis- 
ease is manifested, cases presumably in which the virulent secretion 



CHANCROID. 751 

has remained pocketed in the orifice of a follicle or in a fold of mucous 
membrane, where its irritant effects have finally opened an avenue for 
its deeper ingress. When typically developed the chancroid is seen 
to be a pustular lesion, frequently multiple, of roundish outline, begin- 
ning as a pinhead-sized, turbid vesico-pustule, rapidly enlarging to 
a pea- or bean-sized, well-developed, projecting, yellowish, globoid 
elevation of the epidermis, filled with greenish-yellow pus. When 
located in furrows or depressions of the surface it may have a linear, 
oval, or even a dumb-bell shape, the latter in consequence of extension 
from a sulcus to overlying folds. Clinically the roof-wall of this pus- 
tule is not frequently encountered, the objective symptoms being the 
ulcers which represent the floors of separate lesions. These ulcers 
vary with the shape of the superimposed pustules, being round, ovoid, 
or linear, occasionally irregular in outline, with sharply defined or cut 
edges ; they have an uneven, pus-bathed floor ; a faint pinkish areola ; 
a supple, non-indurated base ; an abundant puriform secretion ; and 
are accompanied or unaccompanied by pain, according to the degree 
of inflammation present. In consequence of the auto-inoculability of 
the discharge these ulcers frequently give rise to others in the vicinity, 
as when the prepuce lies in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of that of 
a pea or of a bean in the course of from ten to fourteen days ; they 
then remain in an indolent and suppurative condition, showing no ten- 
dency to heal for a fortnight or three weeks ; and finally they granulate, 
exhibiting the ordinary phases of repair. The resulting cicatrix is 
either transitory or, more often, indelible. In exceptional cases the 
ulcer spreads widely. In the groin it may attain a diameter of several 
inches ; its floor secreting scantily ; its edges lurid, undermined, pur- 
plish, or ragged ; its color reddish, bluish, purplish, or leaden. Fis- 
tulous tracts and sinuses, filled with an ichorous sero-pus, radiate in 
dependent situations ; the base of the sore is densely indurated ; its 
career may be prolonged for years, and induce finally a systemic 
cachexia not different from that seen in all chronic ulcerations of 
severe grade. In other cases the occurrence of gangrene, or phage- 
dena, changes the features of the lesion to those of other ulcers under- 
going similar metamorphosis. 

Chancroids may occur upon any exposed mucous surface of the geni- 
talia of both sexes, upon the integument of the penis, scrotum, labia, 
thighs, fingers, perineum, peri-anal region, and, very rarely indeed, 
upon the face. In consequence of their tendency to relapse, their 
abundant contagious secretion, and their auto-inoculability, chancroids 
are more frequently encountered than is the primary syphilitic lesion 
among the filthy, the poor, and the classes that frequent hospitals and 
dispensaries. Among the wealthy, the well-to-do, and the cleanly 
this order of frequency is reversed. 

The chancroid ulcer is also much more frequently complicated by 
surgical accidents than is the infecting lesion of syphilis. This result 
is partly due to the prevalence of an ulcerative type in all its manifes- 
tations, and in part to its situation. Thus, the ulcer is often accom- 
panied by severe inflammatory symptoms, which may be aggravated 



752 NEW-GROWTHS. 

both by phimosis and paraphimosis, occurring with stenosis of the 
preputial aperture, or with a long, lax, and redundant foreskin. Pha- 
gedena is also a formidable complication, whether of sloughing or of 
serpiginous tendency, the lesion in each case losing its chancrous char- 
acteristics. It is evident also that the disease may coexist with others 
of a different character. Thus, a single point may simultaneously be 
inoculated with chancroidal and syphilitic virus ; the former, without 
an incubative period, followed rapidly by a pustular or an ulcerative 
lesion ; the latter, after its incubation is complete, producing the char- 
acteristic symptoms of an initial sclerosis. Chancroids may also be 
found coexisting with various early and late syphilitic lesions of the 
genitals, with vegetations, with blennorrhagic discharges and balanitis, 
with pediculi of the pubes, and with herpes progenitalis. Patients of 
the class exhibiting these lesions not infrequently present themselves at 
public dispensaries with three or more of these concurrent disorders. 

One of the most serious complications of the chancroid is its associa- 
tion with a specific lymphangitis, periadenitis, or adenopathy. In this 
case the lymphatic trunks connected with the lesion become inflamed, 
indurated, and irregularly corded, with the overlying integument often 
oedematous, reddened, and painful. The infective process in these 
vessels rarely terminates by suppuration. The bubo of chancroid is 
more common, and this adenopathy may be either sympathetic, resulting 
from the severity of the process at the site of the lesion, or be virulent, 
due to the transmission of an inoculable pus to one or more of the 
glands in near connection with the source of the trouble. These dif- 
ferent gland-complications may coexist in one person, in men more 
often than in women, and in about one of each four or five cases pre- 
sented to observation. When inoculable pus has been formed in a 
neighboring gland the latter is at once converted into the seat of an 
abscess, the pus of which, whether evacuated spontaneously or by the 
knife of the surgeon, speedily inoculates the lips of the wound through 
which exit has been obtained. The wound and contiguous abscess- 
cavity then form a large chancroidal ulcer, usually inguinal in situation, 
as the glands in this locality are nearest the most frequent seat of the 
lesion. Such an inguinal ulcer discharges a greenish-yellow pus often 
commingled with blood; its borders are undermined, thin, livid or 
purplish, and ragged ; its floor is irregular, sloughy, and often covered 
with nodules representing the debris of glandular structure; from it 
depart sinuses traversing the tissues in the vicinity, often downward to 
the thigh, occasionally upward over the belly. When occurring in 
strumous and cachectic subjects, or when long neglected or mismanaged, 
the resulting disorder is of the most serious character, and it may 
surpass in duration and severity certain of the varieties of lupus and 
epithelioma. 

These facts have an important bearing. It is true that syphilis is a 
constitutional disease, and that it usually occurs but once in a lifetime. 
It is equally true that the chancroid is evidence of a local and non- 
systemic disorder, producing only such constitutional effects as may all 
other local affections of chronic course and severe grade ; but it is a 
blunder to suppose for these reasons that the chancroid is the milder 



CHANCROID. 753 

of the two maladies. Many of its consequences are much more severe, 
and some of them even more malignant, than the average of syphilitic 
sequels, and even, as indicated above, are worse than some forms of 
other diseases usually classed as malignant. Greater attention should 
be generally directed to the truth respecting the comparative gravity 
of the two diseases, as there is widespread ignorance of the facts. 

The Pathology of the chancroid, though illustrated by the re- 
searches of Biesiadecki, Auspitz, and Unna, is yet not understood to 
an extent that will explain its specific character. The micro-organisms 
discovered in all coccogenous lesions are usually abundant and readily 
demonstrable. Those recognized by Ducrey, of Naples, 1 are short, 
thick bacilli measuring 1.46 by 0.50 [i. These observations were con- 
firmed by Krefting, of Christiania; 2 while the bacilli discovered and 
claimed as pathogenic by Unna (his observations being later confirmed 
by Quinquaud and Nicolle) occur in the form of twisted coils and 
chains, measuring 1.25 by 0.33 ju. The etiological value of these ob- 
servations remains to be determined. 

Anatomically, there is disclosed by the microscope a uniform, dense 
infiltration of the corium with elements w T hich undoubtedly represent 
inflammatory metamorphosis of the connective tissue of the derma ; de- 
generative changes where the ulceration has proceeded superficially ; 
enlargement of vessels from thickening of their walls, often with 
diminished lumen ; and relatively intact rete and corium at the lateral 
borders of the ulcer. This fully confirms the inferences suggested by 
a clinical study of the disease. Many roundish, circumscribed, clean- 
cut ulcers with purulent floors occur upon the skin that bear no rela- 
tion to the chancroid disease. It is the history and career of the disease 
that stamp it with an individuality of its own. It is not the form and 
appearance of its pus-elements, but their power and potency, w r hich 
make them singular. 

Diagnosis. — Chancroid is to be distinguished from syphilitic 
chancre, but no skill, however great, and no experience, however wide, 
will enable the diagnostician, even when typical chancroid is present, 
to assert that syphilis will not follow, until the longest incubative 
period of the initial sclerosis of the last-named disease has elapsed 
without production of suspicious symptoms. The rule which neces- 
sarily follows is imperative, and, being too frequently ignored, 
bitter disappointment on the part of the infected individual, and 
mortification on the part of the physician, have naturally resulted. 

NO PATIENT SUFFERING FROM A CHANCROID CAN BE PROMISED 
IMMUNITY AGAINST SYPHILIS UNTIL TWO AND A HALF MONTHS 
HAVE ELAPSED AFTER THE DATE OF LAST EXPOSURE. Subject 

to this essential reserve, the diagnosis rests upon the pustular, ulcer- 
ative, and discharging features of the chancroid, its failure to indu- 
rate at the base, its auto-inoculability, its appearance without pre- 
vious incubation, its more formidable localized expression of disease, 
and the characteristics of the accompanying adenopathy. The short- 
lived, superficial vesicles of herpes progenitalis, often accompanied by 

1 Congres internat. de Derm, et de Syph., Paris, 1889, p. 229. 

2 Archiv, 1892, xxiv., p. 41. 

48 



754 NEW-GROWTHS. 

tingling and painful sensations, with sequels in the form of equally 
superficial, epidermal excoriations, are not to be confounded with chan- 
croids ; yet it must be remembered that these lesions may also precede 
or may accompany any form of venereal disorder. Chancroids are to 
be distinguished also from secondary and tertiary lesions of the genitals, 
and from non-syphilitic vegetations and molluscum epitheliale of the 
same region. 

Treatment. — The most effective and ultimately the most satis- 
factory treatment of chancroids is by asepsis patiently carried out. 
Less satisfactory is the routine treatment by destructive cauterization 
with either nitric or sulphuric acid now practically abandoned by the 
ablest practitioners. Keyes recommends a previous application of 
pure carbolic acid, in order to benumb the part and thus render 
the subsequent application less painful. If employed at all, the 
carbolic acid should carefully be wiped from the sore before the 
subsequent cauterization, as the two acids will explode if suddenly 
brought in contact. As the slough separates the ulcer may be dressed 
in accordance with the general principles governing the treatment of 
simple granulating wounds. Special care should be taken by all prac- 
ticable measures to avoid the possibilities of auto-infection. Vinous, 
carbolated, and opiated lotions, painting with a saturated aqueous solu- 
tion of pyoktanin-blue, powders of boric acid, iodoform, iodol, calomel, 
bismuth subnitrate, and starch, simple unguents, and the interposition 
of a pledget of borated cotton between all affected and sound tissues — 
these measures in most cases suffice to insure relief. Pencillings with 
silver nitrate, though ineffective for the purposes of cauterization, often 
answer a good purpose in hastening repair. The prepuce may require 
division or circumcision. 

For grave and extensive ulcerations, accompanied or unaccompanied 
by phagedena or by gangrene, there is no treatment comparable in 
value with the hot water-bath of an average temperature of 98° F. 
For the details of this method the reader is referred to the paragraph 
devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, require 
the surgical treatment appropriate for the relief of those conditions. 
For the accompanying adenopathy in chancroid disease, before sup- 
puration has occurred, rest is essential, with laxatives and gentle local 
compression. When there are great heat and tenderness a few leeches 
may be applied. After pus has formed it may be evacuated with an 
aspirator-needle, or by a free incision in the long axis of the swelling, 
followed by curetting the abscess-cavity and by the usual antiseptic 
dressings. Constitutional treatment by iron, quinine, cod-liver oil, and 
the employment of a generous diet with milk, malt liquors, or wines 
are often required in broken-down and debilitated persons. 

The Prognosis, in uncomplicated cases, is generally favorable. The 
scar left by a suppurating gland in the groin is indelible, but it becomes 
less conspicuous with years. Sloughing and gangrenous sores leave 
deforming cicatrices, especially when occurring at the apex of the glans, 
to which they usually give a peculiarly truncated shape. A just reserve 
should be made in all cases, complicated with syphilis or extensive fistu- 
lous sinuses, the latter, as mentioned above, often persisting for years. 



LEPRA. 755 

LEPRA. 1 

(Gr. Ieirpb5, scaly.) 

(Leprosy, Satyriasis, Elephantiasis Gr^corum, Leontiasis, 
Lepra Arabum. Fr., Lepre, Ladrerie; Ger., Aussatz ; 
Ital. y Lebbra ; Norweg., Spedalskhed.) 

Leprosy is a disease which is supposed to have originated in the 
Orient and to be as old as the records of history. Together with a 
group of dermatoses, probably of a different nature, it is represented 
without question in the " Zaarath " of the Hebrew Scriptures. Once 
prominent in the list of the scourges of the old world, its prevalence 
to-day is restricted in the lands where it still occurs ; and it is the rarest 
of maladies in countries like Great Britain, where it once existed. It is 
found now in Norway, and to a less extent in Sweden ; in Bulgaria, 
Greece, Russia, Austro-Hungary, and Italy, with a much reduced" per- 
centage in middle Europe; in India, Java, and China; in Egypt, 
Algiers, and Southern Africa ; in Australia ; and in both North and 
South, including particularly Central America, Cuba, and the Antilles. 
In the United States it has been recognized chiefly in New 
Orleans, San Francisco (predominantly among the Chinese population 
of that city), and in portions of Minnesota, Wisconsin, and Iowa. Iso- 
lated cases have been recognized in almost every State of the Union. 
Leprous patients are presented not rarely at our clinic in Chicago ; as also 
at the public charities of New York, Philadelphia, Boston, and other 
centres of population. It has been estimated that the number of lepers 
in the United States varies between two hundred and five hundred. 
The disease is represented also in what is reported as a diminishing 
frequency in the dependencies of the United States, the Hawaiian 
Islands, Porto Eico, and the Philippines. 

Symptoms. — In whatever form leprosy may ultimately be mani- 

1 The literature of lepra is voluminous. The references appended include a few of 
the classical and some of the more recent contributions to the subject. Danielssen and 
Boeck, Traite de la Spedalskhed, etc. with atlas, Paris, 1848 ; and Grend, Recueil 
d' observ., etc., Christiania, 1862. Hansen. A., Archiv, 1871, Cong, med., de sc. med. 
de Copenhagen, 1884. Carter, Van Dyke, Leprosy, etc., 1874. Hansen and Looft, 
Wocker, London, 1895. Leloir, Traite de Lepre (planches), Paris, 1886. LTnna 
" Microorg. in Leprosy," Dublin Jour. Med. Sci., July, 1890. Zambaco, Leprosy and 
Syphilis, Int. Cong, of Derm., London, 1896. Lepra-Conferenz, Berlin, Oct., 1897 
(three volumes; full bibliography). Santon, Derm, La Leprose, Paris, 1901 (plates). 
Babes, Victor, Die Lepra, Wien, 1901 (68 illustrations, 8 colored plates, and bibli- 
ography to date). 

Among American contributors may be named: Banes, Arch, of Med., Dec, 1881, 
vi., p. 201 ; Bemiss, New Orleans Med. and Surg. Jour., 1880, n. s., vii., 923 ; Jones, 
Ibid., March, 1878; Dyer, Phila. Med. Jour., 1898, ii., p. 567; Solomen, Trans. 
Louisiana State Medical Association, 1879 ; Morrow, Twentieth Century Practice, vol. 
xv., p. 403, and Jour. Cutan. Dis., 1889, p. 147; Brocken, Minnesota State Board of 
Health, 1901, and Phila. Med. Jour., 1898, ii., p. 1309 ; McDonald, Jonathan T., 
Jour. Amer. Med. Assoc, 1903, xl., p. 1567 (examination of 150 cases in Hawaii) ; 
Montgomery, Douglass W. (spontaneous cure in a leper family), Med. Record, 1902, 
and Jour. Amer. Med. Assoc, 1894, xxiii., p. 136 ; Hyde, Transactions Congress of 
American Physicians and Surgeons, 1894, iii., p. 103 (with bibliography) ; White, J. C, 
Transactions International Leprosy Convention, 1897, vol. i. 



756 NEW-GROWTHS. 

fested, its appearance is preceded usually by the prodromic symptoms 
generally recognized as precursors of severe constitutional disease. 
These symptoms, are : anorexia ; cephalalgia ; chills, alternating with 
mild or with severe febrile attacks ; depression ; epistaxis ; gastrointes- 
tinal disturbances ; and insomnia. Their duration is exceedingly variable; 
in some cases patients will remember that these or similar symp- 
toms preceded for years the earliest outbreak of lepra. In other cases 
but a few weeks' interval occurs between the prodromic and the succes- 
sive stages of the disease. The character of the prodromata furnishes 
no clue to the severity and type of the oncoming disorder. The earlier 
cutaneous lesions of leprosy are tubercular, macular, or bullous. They 
may be coincident or successive, or one or two of these types may so far 
predominate that another either may be wanting altogether or may 
possess in the general pathological history but a trifling significance. 

Fig. 80. 




Tubercular leprosy. 

It has thus been customary to make an entirely artificial distinction 
between cases of leprosy by assigning them to three varieties — tubercu- 
lar, macular, and anaesthetic. It will be understood, then, in 
separately considering these three forms, that the distinction be- 
tween them is useful simply for purposes of clinical classifica- 
tion ; that mixed cases of the disease occur which it would be 
difficult to assign to either variety exclusively ; and that each case 
merely represents a predominance of certain lesions at one patho- 
logical epoch. It should be noted also that the symptoms of leprosy 
are remarkable for their polymorphism, a wide variation often exist- 



LEPRA. 757 

ing between the character of two or more lesions which at any given 
moment are apparent. This variation is owing largely to the fact 
that leprosy is a general and constitutional disorder, the cutaneous 
symptoms of which are simply its surface-markings. 

Lepra Tuberosa (Tuberculated, Nodulated, or Tegumentary 
Leprosy). — From 10 to 50 per cent, of cases are of the nodular type, 
the larger proportions apparently holding good for colder climates. 
After the occurrence of chills and a febrile movement of remittent, 
intermittent, or continuous type, lasting for weeks or months, macular 
lesions appear, which are bean- to tomato-sized, reddish, brownish, or 
bronze-hued patches, roundish, oval, or irregular in contour, well de- 
fined and occurring upon the face, trunk, or extremities. The skin 
covering these lesions is either smooth and shining, as if oiled, or is 

Fig. 81. 




• ':. :.. J 

Tubercular leprosy. 

infiltrated moderately and elevated. The surface of the erythematous 
spots is often hyperaesthetic. After a period ranging in duration from 
weeks to years, tubercles (lepromata) rise from the maculations, vary- 
ing in size from that of a pea to that of a nut, though they may be as 
large as a tomato. They are yellowish, reddish brown, or bronzed in 
color, often shining as if varnished or oiled, are covered with a soft, 
natural, or slightly desquamating epidermis, roundish or irregular in 
contour, and are either isolated or grouped. Numbers of very small 
and ill-determined nodules may often be recognized by careful exami- 
nation of the skin in the vicinity of those fully developed. They may 
fuse and produce broad infiltrations, from the surface of which spring 
new nodules. They may be either cutaneous or subcutaneous in situ- 



758 NEW-GROWTHS. 

ation, and be softish or firm to the touch. The eruption of these 
tubercles is usually at the outset preceded by fever, as well as by 
oedema of the region involved — eyelids, ears, etc. The lesions are 
often in varying grades anaesthetic. 

The site of predilection of leprous tubercles is the face, and their 
massing in great numbers upon this region produces the characteristic 
deformity of the countenance that has given to the disease one of its 
names, Leontiasis (face of a lion). In such faces the tubercles are 
ranged in parallel series above the brows, down the nose, over the 
cheeks, the lips, and the chin. In consequence of the infiltration 
and development of the lesions the brows deeply overhang the globes 
of the eyes, the eyelids become affected with partial ptosis, the lips 
pout, and the ears are so studded with tubercular masses as to project 
from the side of the head. The trunk and extremities, including 
the palmar and plantar surfaces, are then usually to a less degree 
involved. Other parts which may be invaded are the axillae, genital 
and mammary regions, and more rarely the neck and the palms and 
soles. Occasionally, indeed, with extensive development of tubercles 
upon the face and ears, there may not be more than from five to fifty 
tubercles upon the rest of the body, and these either widely dispersed 
and isolated or agglomerated in a single hard, flat, elevated plaque of 
infiltration upon the elbow or the thigh. When confluence of tubercles 
occurs, large plaques of infiltration may form (lepromes en nappe), which 
are elevated and brownish or blackish in shade (morphoea nigra.) In 
yet other cases the condition described by Bazin as leprous scleroderma 
occurs, in which dense infiltrations extend to both the derm and the 
hypoderm. The surface of these lesions is roughened, often desqua- 
mating, rarely ulcerated. 

With these cutaneous lesions there is often involvement of the 
mucous surfaces, especially the velum palati and the larynx. In the 
case of the lepers affected with the tubercular form of this disease, who 
were exhibited at our clinic in 1879 and 1904, 1 there were marked 
gruffness and hoarseness of the voice, and the tongue, the larynx, and 
velum were studded with pinhead- to pea-sized, ashen-hued tubercles. 
Others may form upon the conjunctiva and the Schneiderian membrane, 
the gums, the inside of the cheeks, the tongue, the palate, the fauces, 
and the pharynx. 

These tubercles may degenerate into irregularly outlined, sharply 
cut, glazed ulcers, with a hemorrhagic or sloughing floor, or they may- 
undergo resorption and disappear, leaving pigmented atrophic depres- 
sions, or they lose their shape in consequence of partial resorption. A 
large plaque may flatten centrally until an annular disk is left to indi- 
cate its former site. 

Among the coincident symptoms of the tubercular exanthem in lepra 
may be named : disturbance in the functions of sweat and sebaceous 
secretion, thinning and loss of the hair in the regions implicated (espe- 
cially of the eyebrows), and disorders of sensibility. Later results are 
to be noted in a nasal catarrh from implication of the Schneiderian mem- 

1 Chicago Med. Jour, and Exam., 1879, xxxix., p. 561, with cut showing appearance 
of larynx. 



LEPRA. 759 

brane ; atrophy of the sexual organs in both sexes with impairment or 
total loss of procreative power, and remediless blindness, which may 
result from keratitis, iridocyclitis, or panophthalmia. 

It should be borne in mind, however, that the course of the disease 
is exceedingly slow, and that years may elapse before these several 
changes are accomplished. The malady, indeed, often appears to be 
quiescent for months at a time, after which, with the occurrence of 
fever, acute or subacute manifestations appear, including adenopathy, 
orchitis, slow or relatively rapid ulcerative processes, followed by gan- 
grene ; and a relatively rapid progress is made toward a fatal conclusion. 
Long before the latter is reached there are usually, in tubercular lep- 
rosy (Fig. 79), intermingled symptoms of anaesthetic type, such as the 
occurrence of bullae or of anaesthetic patches with and without pigmenta- 
tion. Toward the last the mutilations effected by the disease may 
result (Lepra Mutilans). Phalanges of the fingers or toes, whole 
digits, an entire hand or foot may then become wholly or partially de- 
tached by ulcerative, atrophic, or other degeneration of skin, bones, and 
ligaments, hastened or not by intercurrent attacks of lymphangitis, 
erysipelas, septicaemia, and irritative fever. 

The stadium of this type of the disease may extend through ten or 
more years. After its full development the dejected countenance of the 
leper, with his leonine facies and general appearance of cachexia, is 
highly characteristic. 

Lepra Maculosa (Maculo-an^sthetic Lepra, Erythema Lep- 
rosum, Leprous Roseola). — This form of the disease is more com- 
mon in tropical than in cold countries and is distinguished chiefly, as 
its name implies, by its macular lesions. These lesions have the gen- 
eral character of those described as preceding the appearance of the 
leprous tubercles. In size they vary from that of a small coin to areas 
as large as a platter. They are diffused or circumscribed, roundish or 
irregularly shaped, and in color yellowish, brownish, or bronzed, often 
shining or glazed. They may be infiltrated, and may be raised slightly 
from, or on a level with, the adjacent tissues. At times they appear as 
lardaceous deposits in the skin, whitish, reddish, or even blackish in 
color, with a telangiectasic border. These patches are usually at first 
hyperaesthetic, but finally they become insensitive, so that a lancet can 
be thrust deeply into them without producing the slightest sensation. 

The pigment-variations in macular lepra are noticeable. At times 
a distinctly anaesthetic patch may readily be limited by its lack of 
sensation and of normal color ; at other times either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus, a palm- to platter-sized, texturally unaltered area over the thigh 
or the belly may suggest a vitiligo by its relatively slight pigmenta- 
tion and its distinct contour, beyond which are sepia to deep chocolate 
tints, gradually fading toward some adjacent and similarly involved 
patch. Yet this area will often differ materially from that of vitiligo 
in other respects. Every inch of the former may be totally insensi- 
tive to the prick of the lancet, and, moreover, be of a dull, tawny, 
yellowish, or parchment-like hue, never having the peculiar milky- 
white tinge of vitiligo. Again, this anaesthesia may extend widely 



760 NEW-GROWTHS. 

beyond the line traced by the pigment-anomaly, or even within the 
latter may vary, islets of skin capable of perceiving sensations being in 
cases here and there discernible. The regions chiefly affected are : the 
back, the exposed parts, the backs of the hands and wrists, the forehead, 
cheeks, ears, dorsum of feet, and ankles. The eruption may be scanty 
or general : conspicuous or so insignificant as to escape attention save 
when closely scrutinized. A few bullae may be intermingled with the 
macules, the skin otherwise being texturally unaltered. The eruptive 
symptoms are associated commonly, early or late, with the graver 
phenomena described below. 

Lepra Ansesthetica (Lepra Trophoneurotica, Nerve-leprosy 
Atrophic Leprosy). — There may be one or two years of ill-health 
preceding the development of this form of lepra, the patient suffer- 
ing from chills and vague sensations of malaise. Usually at this 
time the skin becomes hyperaesthetic in localized patches, some- 
times generally ; and special nerves in consequence of their enlargement 
become accessible to the touch. Those especially named below become 
tender and the seat of lancinating or shooting pains. This clinical 
variety, as has been described, may be commingled in its symp- 
toms with each of the other types. With and without such com- 
mingling, however, there commonly is noted after exposure to cold, 
or after being subject to chills first an eruption of erythematous 
patches or of bullae, bean- to large-nut-sized, with a roof-wall 
constituted of the entire thickness of the epidermis, filled with a 
clear-tinted or blood-mixed serum, occurring usually upon the extremi- 
ties. The cicatrices which follow these bullae are atrophic patches, each 
often far greater in extent than the base of the original bleb, whitish, 
shining, glazed, or better described as of a tint suggesting the hue of 
mica ; circular in outline, forming also the dumb-bell figure by coales- 
cence or juxtaposition. These cicatrices are always anaesthetic, and 
they may coexist with macular and anaesthetic patches upon the trunk 
or other portions of the body : face, hands, feet, ankles, thighs — rarely 
the palms and soles. Neither those of the one class nor of the other, 
however, are disposed over the surface of the body in lines, bands, or 
curves corresponding with the distribution of the cutaneous nerves. 
Asymmetry is the rule. Occasionally, however, the ulnar and other 
nerves (median, posterior tibial, peroneal, facial, and radial) accessible 
to the touch are tumid, tender, insensitive, or as rigid as indurated 
cords ; fusiform, reddish-gray swellings may be recognized with the 
naked eye along the nerve-tract, with translucent and gelatinous aspect. 
General atrophic cutaneous symptoms follow : the skin becomes dry 
and harsh ; there is manifestly little or no sebaceous product ; the sweat 
is scanty ; the muscles atrophy ; the hairs fall ; the lymphatic ganglia 
enlarge ; the skin of the face seems tightly stretched over the bones. 
As a result of deforming atrophy of the eyelids epiphora and conse- 
quent orbicular changes ensue, and the parted lips permit constant 
escape of saliva. The fingers are half-drawn into the palm of the 
hand ; the nails are distorted, and, later, ulceration occurs (Fig. 82).^ 

The ulcers are irregular, oval, roundish, linear ; covered with thin, 
blackish, flattened, tenacious, never rupioid, crusts; their bases are 



LEPRA. 



761 



soft ; their floors covered with a pultaceous debris often mixed with 
blood ; the whole usually insensitive to every foreign body and external 
application. Lastly, the symptoms of lepra mutilans may occur, digits, 
or portions of the carpus, metacarpus, or corresponding parts of the 
foot, being detached from the body. 

Death may ensue, at any time during the course of the disease, from 
septicaemia, exhaustion, or any of the intercurrent affections to which a 
patient in such a condition is particularly disposed. Thus, a leper was 
accidentally choked to death in San Francisco by some perversion of 
the function of deglutition. The disease, however, in the ansesthetic 
form is said to last from eighteen to twenty years, and is thus less 
rapidly fatal than the tubercular variety. 

Fig. 82. 




Ansesthetic leprosy with mutilating results. (From a photograph of a leper in the Sandwich 

Islands.) 



Considering the several clinical varieties of leprosy named above, 
and the mixed forms resulting from a commingling in some cases of 
the features of all varieties, the result is merely an analysis of the 



762 NEW-GROWTHS. 

symptoms in an enormous clinical field. There are not, in fact, any 
forms or varieties of this disorder ; there is but one disease, which ex- 
hibits itself in widely differing manifestations, and these at one time 
and in one country assume a predominant phase, while with a differ- 
ent environment and in another race other phenomena appear. Thus, 
lepra tuberosa is reported in from 50 to 75 per cent, of patients affected 
with the disease in the north of Europe, and in from 10 to 20 per cent, 
of those in tropical countries ; while anaesthetic lepra in the geograph- 
ical limits last named is represented by two-thirds of patients, and in 
the northern latitudes by less than one-third. "Mixed forms' 7 are less 
often reported than others, but as a matter of fact are the more often 
observed. The reason for this apparent anomaly lies in the fact that 
really pure cases of any form are rare. It is best to look upon the 
expressions of lepra as it is accepted to regard the phenomena of syph- 
ilis : in each there is a single morbid principle ; there are in both no 
true varieties ; and the external symptoms differ chiefly because of 
special accidents of environment, of race, or of individual peculiarities. 

Looking at the variant symptoms of lepra, a wide range occurs in 
all stages. In the evolution of the disease there is a usual order of 
fever, eruptive symptoms, and ulcerative or destructive sequels. In 
the prodromic period there are often chilliness, profuse diaphoresis, in- 
somnia, inappetence, diarrhoea, vertigo, and even a bullous efflorescence 
upon the surface. These prodromata are rarely wanting, and, after 
lasting for weeks, months, or years, are followed by sensations of chil- 
liness, with remitting or intermitting febrile symptoms, the temperature 
rising from 100° to 105° F. The tongue becomes of a reddish hue, 
the listlessness and sluggishness continue, and the typical cutaneous 
lesions of the disease (leprous spots) appear, commonly on some portions 
of the face, with or without oedema. In some cases the prodromic 
symptoms and fever and chilliness are either absent or, what is more 
probable, are unnoticed, and then the disease may be first recognized 
by pains of a lancinating character, tenderness, and aching, especially 
along the course of the ulnar, peroneal, median, saphenous, or other 
nerves ; or the result may be hyperaesthesia, anaesthesia, or pricking, 
tingling, and similar sensations in regions supplied by special nerves. 
The greatest variation is observed in the length of time during which 
these early symptoms, with more or less vagueness of expression, exist. 
Later, tubercles, nodules, bullae, macules, hyperaesthetic and anaesthetic 
patches appear with gradual development of other and non-cutaneous 
symptoms, paralysis, exaggerated tendon-reflexes, and atheromatous 
papules upon the palpebral membranes and cornea. At times there 
results an ulcerative keratitis. In every large leper-hospital the number 
of inmates, both men and women, who have become totally blind in 
consequence of the ravages of the disease is considerable. In many, 
too, nodules appear over the chest, genital regions, and extremities, as 
well as upon the mucous surfaces of the mouth and respiratory tract. 
The voice becomes raucous, while recrudescences of the disease occur 
either along the one (tubercular) or the other (anaesthetic) line toward 
the final stages of degeneration and mutilation. 

The disease in seen in all typical forms, even in regions where leprosy 



LEPRA. 763 

is least prevalent. There may be a genuine leprous pachydermia with 
enormous increase in the volume of the hands and feet, accompanied 
by severe onychia and paronychia, and deep ulcerations about the nails. 
In some cases tumefaction of an entire limb results, strongly resembling 
an elephantiasis. The nose may be stuifed with leprous tubercles ; and 
a large number of cutaneous symptoms of the most varying type 
develop in and upon the leprous skin as the result of secondary infec- 
tion, of accidents, or of invasion by pus-cocci, etc., for it must be remem- 
bered that in most cases the leprous belong to the filthy and impover- 
ished classes of society. Thus, there are often developed eczemas, 
erythematous and achromic and hyperchromic spots and disks, annu- 
lar lesions resembling those seen in syphilis, bulla? rapidly becoming 
gangrenous (erytheme polymorphe lepreux bulleux et escharotique, of 
Leloir), nodules of the usual size and hue of those in lepra (pinhead- to 
nut-sized, pigmented, reddish brown, copper tinted, glazed, shining as 
if oiled), and enormous infiltrations within and below the derma, even 
the production of large tumors of leprous tissue. 

The generative apparatus may seriously be involved, the uterus, 
Fallopian tubes, and ovaries being the seat of leprous nodules or diffuse 
lepromatous infiltrations ; as may be also the testicles, prostate gland, 
and penis. The breasts are also stuffed with tubercles ; but they, as 
also the other organs named, may simply waste under the influence 
of the disease. Sexual power is retained longer than is commonly 
believed. In the colored races the eruptive symptoms are tinted in 
yellowish and reddish shades, a result due to contrast with the hue of 
pigmented skins. 

Etiology. — Leprosy is a contagious and infectious parasitic disorder 
produced by the bacillus leprae. This organism was discovered by 
Armauer Hansen in 1874, and is present in large numbers in tubercular 
forms of the disease, being relatively absent in anaesthetic lepra. It 
strongly resembles the bacillus of tuberculosis. These bacilli have been 
found in the dwellings and clothing of lepers as Avell as in the dust of 
apartments occupied by victims of the disease. 

Secretions of a leprous patient containing bacilli or their spores are 
the usual vehicle by which the disease is transmitted. The question 
of the inheritance of leprosy may be regarded to-day as in much the 
same position as that relating to the inheritance of tuberculosis ; no 
foetus, no newborn living child has been known to exhibit the symptoms 
of either disease. Babes, however, cites several cases w T here infants 
but a few weeks old exhibited symptoms of leprosy. Men are affected 
with the disease more often than Avomen. Infection is more common 
after the second decade, though children are occasionally among its 
victims. 

The geographical distribution of leprosy is widely extended. In 
countries where it has not previously existed its appearance is due inva- 
riably to the infection of sound individuals by lepers first exhibiting 
symptoms where the disease is prevalent. Neisser formulates the law 
of its prevalence by stating that the number of lepers in any country 
bears an inverse ratio to the laws executed for the care and isolation 
of infected persons. 




764 NEW-GROWTHS. 

With a wide geographical distribution, the disease exists endem- 
ically in certain countries, and also in certain regions of the same 

country, with greater frequency than in 
others. All attempts, however, to connect 
its origin with malaria, with a residence 
near inundated sea-marshes, with the inges- 
tion of a diet consisting largely of fish, or 
of a diet from which salt largely has been 
excluded, have failed of recognized success. 
The disease, however, seems to spread more 
rapidly in damp and cold, or warm and 
moist climates than in temperate countries. 
Larvnx^f a'patient affected It is true that probably the larger number 
rutho^ r c a aseso r ° Sa ' (0neofthe of all living lepers are those who have been 

poorly fed and otherwise subjected to the 
most insalubrious of influences, but the disease also attacks, though 
far more rarely, persons whose social position and hygienic surround- 
ings are of the best. It occurs in both sexes — though more frequently 
in men — and at all ages ; and, despite all effort to show the contrary, 
bears no relation to syphilis. Lepers, however, become syphilitic if 
infected with that disease, precisely as they may and do acquire variola, 
varicella, morbilli, erysipelas, and phthisis. The Hebrew Scriptures 
are often interpreted as showing that the disease among the Jews in 
Palestine was regarded by them as contagious and so treated. The 
modern student of these writings will, however, be convinced that this 
interpretation is erroneous. The leprosy of the book of Leviticus not 
only includes lepra, as that term is understood to-day, but also psoriasis, 
scabies, and other cutaneous affections. The leper, in the eye of the 
Mosaic law, was ceremonially unclean, and capable of communicating 
only a ceremonial uncleanness. Several of the narratives contained in 
these books bear witness to the fact that the Oriental leper was occa- 
sionally seen doing service in the courts of kings, and even in personal 
communication and contact with officers of high rank. 

Pathology. — The bacillus of leprosy is a delicate rod-shaped, 
straight, or slightly curved parasite from one-half to three-fourths 
of the diameter of a red blood-corpuscle in length, and about one-fifth 
as broad as long. It often is pointed at one extremity. The bacilli 
of leprosy are morphologically almost identical with those of tubercu- 
losis, but are found in affected tissues in vastly greater numbers, ap- 
pearing usually in clumps, and responding more promptly to staining 
and decolorizing agents. These micro-organisms have been found in 
nearly all the tissues of the body, and especially in the skin, mucous 
membranes, interstitial tissue of the peripheral nerves, in the cartilages, 
cornea, spleen, liver, lymphatic glands, sebaceous glands, and hair- 
follicles, also less abundantly in the testicles, spermatic cords, ovaries, 
and walls of the blood-vessels. They do not occur in the muscles, 
spinal cord, bones, or joints, and are wanting in many secondary in- 
flammatory lesions, such as bullae on the surface of the skin. They 
are rarely found in the epidermis, and though it is claimed that they 




LEPRA. 765 

are visible in the blood, their discovery in that fluid has been effected 
rarely. The bacilli are not found in physiological secretions unless 
these be pathologically altered by 

an organ or membrane affected with Fig. 84. 

leprous infiltration. They have 
never been found in urine or in / 

menstrual blood. - d 

The parasites are most numerous _^ 

in comparatively recent but fully 
developed nodes of the skin. Such 
a node on section shows in the 
centre a brownish mass or " glo- 
bus/' which sometimes can be 
shaken out of the surrounding tis- 
sue, and which on examination 
proves to be composed almost en- 
tirely of masses of bacilli. Even / 
in the diffuse form of infiltration / 
the bacilli are usually found in 

i , , i i Bacilli of leprosy: a, epithelial scale. About 

groups^ Or masses, but they may be x 1200 . (From one of the authors' patients.) 

disseminated through the tissues. 

According to Hansen and Looft, the bacilli are almost invariably situ- 
ated within a " lepra-cell," or occasionally in endothelial cells of the 
vessels, or in white blood-corpuscles. Unna and others, on the con- 
trary, have found the bacilli without the cells. Most " investigators 
agree with the observations first cited, but think it probable that there 
are a few free bacilli, and also some in the lymph-channels. 

Unlike the bacilli of tuberculosis, those of leprosy apparently do 
not live or grow outside the living human body. Campana and Ducrey 
obtained cultures, as they supposed, of the lepra-bacillus, but did not 
verify their results by inoculation-experiments, and their conclusions 
are not generally accepted. Practically, the bacillus has not yet been 
cultivated. Attempts to inoculate lower animals with leprous tissue 
have given no definite results. Numerous attempts have been made to 
inoculate human beings with leprosy, but the disease developed in only 
one of the inoculated individuals, and as he was a member of a leprous 
family the result cannot be considered conclusive. 

The introduction into living tissues of leprous material containing 
bacilli results simply in a local inflammation such as would be pro- 
duced by the introduction of any inert substance. In such experiments 
the leprous tissue, which had been hardened for months in alcohol, was 
equally effective with the fresh tissue. Besnier and others believe that 
the bacilli die with the tissue in which they have lived, and thus 
account for the failure of culture- and inoculation-experiments. The 
slight viability of the bacilli is largely responsible for the usual 
benignity and slow progress of the disease. 

In tubercular leprosy the chief histological changes are seen in the 
corium, the nodule being made up chiefly of granulation-tissue similar 
to that seen in lupus and syphilis ; but the leprous tissue is less vascu- 
lar and consequently undergoes formative and retrogressive changes 



766 NEW-GROWTHS. 

less rapidly ; the cells are larger than in the two other diseases named, 
and do not form in nests, as in lupus. The cells, which probably origi- 
nate in endothelial cells of the vessels or in migrated cells, are seen in 
varying sizes and usually filled with bacilli to form the " lepra-cells." 
Giant-cells are also seen. 

The infiltration may be diffuse as well as nodular, and is most 
marked at first about the vessels, glands, and follicles. Later it may 
obliterate the papillae and their line of union with the rete, and extend 
to the subcutaneous tissue. The external and middle coats of the 
vessels are infiltrated and thickened and their lumen narrowed. The 
sebaceous and coil-glands and the follicles are involved early, at first 
undergoing infiltration and hyperplasia, later degenerating and disap- 
pearing. The epidermis is involved secondarily only, and may be thus 
thinned and atrophied or broken in the formation of ulcers. 

In macular and anaesthetic leprosy Hansen and Looft state that 
" the macules are, like the nodules, leprous infiltrations of the cutis, 
consisting of round epithelioid and spindle-cells, the latter being more 
numerous the greater the age of the macule. These infiltrations appear 
to proceed from the vessels. Lepra-bacilli are always present, but are 
most numerous in the younger macules. In the young not as yet 
anaesthetic macules the nerve-twigs appear unchanged ; in the older 
ones they are usually affected." The essential nerve-changes are an 
infiltration of cells containing bacilli within the external sheath and 
between the nerve-fibres, resulting in a gradual disappearance of the 
latter as a res*ult of pressure produced by the great increase of intersti- 
tial connective tissue. The irritation of the nerve-fibres in the early 
stages accounts for the pains and hyperaesthesia ; the nerve is also 
increased in size, often to a marked degree. Later there are atrophy 
and shrinking of the nerve, of which many of the original fibres have 
been destroyed and replaced by connective tissue, with resulting anaes- 
thesia. The peripheral nerves are thus frequently affected, but in the 
brain and cord leprous changes have not been demonstrated. In a few 
cases of anaesthetic leprosy degeneration and atrophy of the posterior 
columns, posterior roots, and spinal ganglia have been demonstrated, as 
well as other changes probably due to an associated tuberculosis which 
is not infrequently present. 

Regarding the disappearance of leprous lesions and tissue, Hansen 
and Looft say that in both the nodular and the maculo-anaesthetic forms 
"the bacilli in the leprous products break up into granules which 
finally disappear, and there remains of the leprous products only a scar 
in which nothing leprous can be recognized. Occasionally this takes 
place in all the affected parts, and there remains only a widespread 
anaesthesia, the result of the nerve-affection ; and in the maculo-anaes-. 
thetic form this is the regular termination of the disease. In both 
cases the leprosy is completely healed." Jeanselme 1 concludes that 
after complete invasion of the subject the bacilli of lepra may utterly 
disappear, leaving only a sclerosis in their track. 

Diagnosis. — Apart from the history, present and previous places of 
residence of the subject of the disease, and the clinical symptoms 
1 La Presse med., 1900, ii., pp. 375 and 388. 



LEPRA. 767 

exhibited, the diagnosis of lepra is to be established by the presence of 
lepra-bacilli. These organisms may be recognized in the tissues, in 
serum obtained artificially from involved regions, in blood made to 
exude from lepromatous nodules, and in the secretions of ulcers. 
Spronck asserts that the agglutinating power of the serum of the 
leprous produces a characteristic reaction in the bacilli reproduced by 
cultures obtained by Hansen's method. 

In Avell-marked cases the recognition of leprosy is simple. In its 
prodromic periods no suspicion of its existence would be awakened in 
countries where the disease is not endemic. 

From syphilis, which is also a disorder the lesions of which are 
polymorphic in character, lepra can be distinguished by its much 
greater chronicity ; its larger and brownish-yellow, glazed tubercles ; 
its frequently paresthetic and anaesthetic symptoms ; its bullous lesions, 
rare in acquired syphilis ; the far more extended areas of its erythema- 
tous macules ; its blackish crusts, lacking the rupioid aspect of those in 
syphilis ; its leathery, mica-tinted cicatrices ; and the characteristic 
leonine facies of its tubercular forms. 

Morphoea and vitiligo are unattended by constitutional changes, and 
more particularly exhibit no hyperaesthetic nor anaesthetic symptoms in 
the affected patches. The atrophic and often deeply pigmented condi- 
tion of the skin in the final stages of pityriasis rubra, associated with 
the emaciation and febrile condition of the patient, might for a time 
mislead the observer who had not a full history of the case. Multiple 
sarcomata, especially upon the face, are followed by much more rapid 
degeneration and a fatal result. 

All lesions of erythema multiforme can readily be distinguished 
from those of lepra by the absence of hyperaesthetic or of anaesthetic 
symptoms. Syringomyelia is differentiated by its display of lesions 
only in regions where there is also muscular atrophy ; by the much 
greater extent and lack of definition of areas of perturbed sensation ; 
by diminution of the tendon-reflexes, which may be exaggerated in 
lepra ; by a marked predominance of symptoms in the upper as distin- 
guished from the lower extremities ; and by the frequent presence of 
scoliosis. The nodules of lupus are not symmetrical, are far softer, and 
are much more often grouped than those of lepra. Further, they never 
have the size of the larger leprous tubercles, and never have the peculiar 
pigmented, brownish, and oiled or varnished aspect of leprous nodules. 

Finally, the diagnosis of leprosy requires not only clinical symp- 
toms, but also a definite contagion. Whether a history of transmis- 
sion from one individual to another be or be not obtainable, it is certain 
that no person ever manifests leprous symptoms who has not been 
infected by some victim of the disease. 

Treatment. — One of the most important considerations relative to 
the therapy of leprosy is that requiring the segregation and isolation 
of all lepers from contact with the uninfected. In some countries, 
those particularly where leprosy prevails, wholesome laws enforce this 
separation of the infected, and charitably provide also for the care of 
the wretched victims of the disease. In America, where leprosy, in 
consequence of its relative rarity, has not yet awakened the attention 



768 • NEW-GROWTHS. 

of legislators beyond the point of forbidding the entry of infected 
persons, the proper care of lepers in a community only too ready to 
take alarm even at the name of the disease is a serious matter. Many 
of the public hospitals for the care of the sick poor refuse to receive 
lepers. In several States of the Northwest the officers of health-boards 
are powerless to make proper provision for the care of a leper whose 
case is brought to their attention. In some of the American colonies 
provision is made for the care of lepers, as at Molokai in the Hawaiian 
Islands. 

The child of a leprous woman should be removed from the mother 
after birth and not given another woman's breast. 

No remedies are known to have a directly curative effect in leprosy. 
As a consequence, the treatment of the disease is that suggested to the 
intelligent practitioner by the indications in each case. Most impor- 
tant, when the patient happens to reside in a district where the disease 
prevails, is an immediate change of residence and climate ; the adop- 
tion of a highly nutritious diet ; and the exhibition of roborant reme- 
dies, including steel, quinine, cod-liver oil, and often the moderate use 
of wines and malt liquors. 

Chaulmoogra oil, which is obtained from the seeds of Gynocardia 
odorata, has the highest reputation in the treatment of leprosy. It is 
given in milk, in emulsion, or in capsule, in doses varying from a few 
minims to 200 and even 500 in twenty-four hours. Crocker reports 
an instance of a leper " perfectly cured " who had taken the oil in the 
larger doses named. Gynocardie acid (its active principle) is adminis- 
tered as a salt in combination with either sodium or magnesium, in 
doses of J to 3 grains (0.033 to 2.). The oil has also been injected 
subcutaneously, 5 grammes (75 grains) daily. Strychnine is added to 
the oil with advantage in some cases. Gurjun oil, obtained from Dip- 
terocarpus lsevis, emulsified, 1 part with 3 parts of lime-water, is also 
given in J ounce (15.) doses twice daily. Frictions with both oils are 
said to induce resorption of the nodules. De Brun and Unna claim 
success with the administration of ichthyol, 2 drachms (10 grammes) 
being administered internally in twenty-four hours. 

While the internal administration of mercury by the mouth has not 
been found useful, Crocker recommends injections of the bichloride of 
mercury, J grain (0.016) to 20 minims of water, in the buttock twice 
weekly. 

The injection of antivenene, the Carrasquilla serum, and other 
modes of serum-therapy have not been followed by results confirmed 
by experience. The cinchonas and salicylates are indicated in febrile 
conditions. Mercury, quinine, arsenic, cod-liver oil, strychnine, the 
iodine compounds, hoang-nan in pills of 3 grains (0.266) ; creosote in 
half-drop doses (0.033) ; the oil of cashew-nut, chrysarobin, pyrogallol, 
resorcin, 10 per cent, solution of salicylic acid in oleic acid (Arning), 
have all been employed with varying success by different practitioners ; 
but an unprejudiced review of the maximum of results thus obtained 
establishes the conviction that no one of the remedies named may be 
regarded as exercising a controlling influence over the disease. Most 
of them have been employed by physicians sufficiently wise to enforce 



FBAMBCSSIA. 769 

simultaneously the most generous tonic regimen, thus clouding with 
doubt a belief in the part played by the medicament in the production 
of the result. In the case of a leper and his daughter in Nebraska, 
who were treated by us for some time with chaulmoogra oil, marked 
benefit was noticeable in the course of a few months, a result probably 
due to the salubrious surroundings of a farm in the country. 

D. "W. Montgomery, 1 Ehlers, 2 Calenheim, Thin, and others have 
reported cases both of spontaneous cure of lepra and also cures of the 
disease by medication. One such instance was shown to us by Lie in 
Bergen. 

Prognosis. — The future of the leper is in general dark. The dis- 
ease is often malignant in character, and, however protracted, a fatal 
result has been the rule. Still, with a change of climate and improved 
hygienic conditions much may be accomplished. There can be no 
question that the Scandinavian lepers who have removed to the United 
States have been benefited greatly by the change. This, indeed, was 
the opinion of the late Professor Boeck, who visited Minnesota, and 
there studied the history of eighteen leprous immigrants who had come 
from Norway. He believed that the change in some cases would work 
a complete arrest of the disease. A careful study of the history of 
leprosy in America will induce the belief that such a favorable result 
can be anticipated after residence in the Northwestern States, as well 
as in other portions of the country. We have lately been enabled to 
insure very marked improvement in an Australian leper under our 
charge by pursuing the measures suggested above. Cases of both 
maculo-anaesthetic and tubercular lepra, concluding with complete 
recovery, are now sufficiently numerous to suggest that the prognosis 
of the malady in the future may be much more favorable. 

The Sartian Disease (Taschkent-geschwur) is an infectious 
granuloma, described by Heiman, and microscopically examined by 
Rudniew. It occurs in Taschkent, or Taschkend, a market-town of 
Asiatic Russia, west of the Caspian Sea. The disease affects the face, 
the upper extremities, and the trunk, avoiding always the palmar and 
plantar regions. Reddish macules develop into nodules, which des- 
quamate, coalesce, degenerate, and leave crusted ulcers, which may 
cicatrize. 

FRAMBCESIA. 

( Fr. framboise, raspberry. ) 

(Yaws, Pian, Lepra Fungifera, Toboe, Polypapilloma Trop- 
icum, schwammformige, bubas or boba, boitton d'amboine, 
Tonga, Coco, Framosi, Tetia, Lupani, Tomo, Peruvian 
Wart, Parangi.) 

Frambesia is an infectious and contagious disorder existing as an 
endemic malady in certain tropical countries, and affecting for the most 
part individuals of the African race. 3 

1 Med. Kec, 1902. 2 La Lepre, 1901, ii., p. 15 ; Ibid., p. 53. 

3 For full discussion of the subject and bibliography, see Scheube, Diseases of Warm 
Countries, p. 290; and Manson, Tropical Diseases, p. 455, 

49 



770 NEW-GROWTHS. 

Symptoms. — There are two defined stages of the disease : one of 
incubation ; another of invasion. In the first stage there may be mod- 
erate febrile symptoms ; in the second stage there are usually malaise, 
articular pains, tenderness and fulness of the lymphatic ganglia, and an 
eruption consisting of tubercles which requires from two to nine days 
for complete evolution, the disease lasting from two to six months in 
mild cases, and in severe forms for two years or more. The aggra- 
vating influences determining the longer periods of the disease are : 
lack of hygienic surroundings, improper medicinal treatment (e. g., the 
administration of mercury under the supposition that the disease is 
syphilitic), and the dyscrasias in general. The eruptive phenomena are 
described under several heads : 

(a) Pian dartre (" yaws caeca "), in which there occurs on the face 
and extremities a furfuraceous desquamation which is usually well 
defined and limited to patches ranging in size from that of a small 
coin to that of a pea. This desquamation may extend over the entire 
surface of the body. In some instances, when the scales are removed, 
papillary projections are visible beneath. 

(b) The yaws tubercle. The tubercle of frambesia varies in size 
from that of a millet-seed to that of a small coin, covered at first with 
a thinned epidermis and later forming an excrescence of verrucous type 
with numerous aggregated pinkish points which furnish a secretion, 
desiccating later into a greenish-yellow, bulky crust, shaped like the 
shell of the limpet and resembling in color and consistency lumps of 
yellow beeswax. Reddish puncta, due to small hemorrhages, may here 
and there be visible at the surface. Crusts are less likely to form 
in regions near the mucous outlets of the body (vulva, anus), and at 
points subjected to friction (axilla?, groins). There may be a delicate 
halo about each crust. The odor is mawkish. A degree of symmetry 
may be perceptible. By confluence a few unusually large excrescences 
(" mama pian ") may form. While the larger are thus coalescing and 
enlarging other smaller tubercles may shrivel and disappear. 

(c) Pian gratelle (" guinea-corn yaws "), which is the rarest form of 
all, is characterized by the development of watery-looking, light pur- 
plish-hued tubercles destitute of crusts. 

(d) Crapeaux ("crab-yaws"). In these cases fissures occur in the 
tubercles which usually are located on the soles of the feet and are 
aggravated by the exposure of these organs when walking barefoot. 
Exuberant granulations often spring from the ulcerating fissures ; in 
other cases cribriform openings are made in the thickened epidermis, 
from which is poured a copious discharge (" running crab-yaws "). 

(e) Ringworm yaws. The eruption may occur in circular ridges 
surrounding an unaffected centre, the original lesions of this enclosed 
area having undergone a species of shrivelling. When this process is 
completed by the fall of the crusts no scars are left, the epidermis being 
pigmented as after the involution of syphilitic tubercles. 

Under unfavorable conditions ulceration of the tubercles occurs, 
leaving raw patches (often on the anterior faces of the legs) ranging in 
size from that of a small coin to areas having a diameter of several 
inches. Their edges are punched out in appearance; the floors are 
granular and bright reddish in hue. 



FRAMBCES1A. 771 

Diagnosis. — The distinction between framboesia and psoriasis and 
eczema is readily effected by consideration of the distinctive peculiari- 
ties of the several disorders named. It is chiefly the distinction from 
syphilis that has engendered confusion in the past. The following are 
important points of distinction : syphilis often, yaws rarely, attacks the 
mucous surfaces, the last-named disease much more rarely involving 
the lymphatic glands ; there is usually itching in the yaws eruption ; 
there is no characteristic copper color in its eruptive features ; yaws 
does not affect the bones save in the continuity of long-standing ulcer- 
ation of the skin ; the subject of yaws is susceptible to indefinite auto- 
inoculation ; yaws though common in children is not inherited ; healthy 
parents may have infants seriously affected with frambesia ; lastly, the 
two diseases often concur in the same person. 

Etiology. — The disease is endemic in certain tropical countries, 
occurring chiefly in the black races and especially among the filthy, 
though it is seen also among the whites. 

Pathology. — The disease, according to Pierez, is caused by a spe- 
cific microbe — a rod-shaped bacillus — occurring singly and also in 
couplets and triplets, and being about 2 fi in length and 0.5 fi in 
breadth. It is cultivated readily in nutrient jelly, and is capable of 
transference, with production of yaws not only upon the skin of man, 
but also upon that of the lower animals, especially the cat. Other 
micro-organisms have been recognized by Eijkmann, Breda, JNTicholls, 
Watts, and Hirsch, some corresponding in description with those dis- 
covered by Pierez ; others (micrococci and bacilli), though capable of 
culture on media, not reproducing the disease artificially. 

The cutaneous tumors are granulomata composed of round and 
spindle-shaped elements in a vascular network of connective-tissue cells. 
The focus of the morbid process is in the papilla and overlying rete at 
the site of the elementary node. 

Treatment. — The disease yields readily in the simpler cases to mild 
parasiticides ; in severe cases tonics are required internally, such as 
iron, quinine, and strychnine. 

The Prognosis is favorable save in infants and broken-down sub- 
jects of other maladies. 

VERRUGA PERUANA. 1 

(Sp., Verruga, wart.) 

(Peruvian Wart, Oroya Fever, Carrion's Disease.) 

Verruga Peruana was described first in the sixteenth century by 
Zarate, of Lima, in his History of the Conquest of Peru (1543). J. J. 
Tschudi, in 1845 (vide infra), contributed the first scientific observation 

1 Chastaing, Arch, de Med. naval., Dec, 1897, p. 417 ; Firth, Allbutt's System, vol. ii., 
p. 496 ; Letulle, Compte Rend, de la Soc. biol., 1898, xv., p. 764 ; Morrow's System, vol. 
iii., p. 694 ; Xicolle, Ann. de l'lnst. Past., 1898, xii., p. 591 ; Obriozola, E., La Maladie de 
Carrion, ou la Verruga Peruv. Paris, 1898 ; Manson, Tropical Diseases, p. 498 ; Scheube, 
Diseases of Warm Countries, p. 298 (bibliography) ; Ramirez del Villar, Inaug. Diss., 
Berlin, 1895 : Ruge, Berlin, klin. Wchnsehrft., 1897, p. 1005 ; Stelwagon, Diseases of the 
Skin, p. 793 ; Tschudi. Arch. f. phvs. Heilk., 1845, p. 378 ; Oesterreich. med.Wchnschrft., 
1846, p. 505, and Wien. med. Wchnschrft., 1872, p. 240. 



772 NEW-GROWTHS. 

of the disease. It is a malady formerly widely distributed in certain 
of the valleys of the Andes in Peru, at an elevation of from 3000 to 
10,000 feet above the sea-level, the wind-protected gorges being endem- 
ically affected, though at present somewhat restricted in its extent. 
The disease is supposed to have been observed also in Ecuador, Bolivia, 
and Chile. Stel wagon has treated one case in Philadelphia. 

Symptoms. — The disease is ushered in with severe rheumatoid pains 
and fever, lasting for weeks or months, the latter often intermitting, 
producing grave anaemia, and accompanied by splenic and hepatic 
changes. Often there are evidences of profound prostration with 
symptoms strongly suggestive of " congestive chills " in tropical and 
malarial districts. In grave cases there may be a fatal issue before the 
development of cutaneous symptoms. 

The skin-manifestations may appear on subsidence of the constitu- 
tional disturbance, though the latter may recur after the exanthem 
develops. At first the lesions are slightly elevated pinkish or reddish 
macules, which later assume a dusky bluish-red hue. From these 
spring conical hemi-globoid elevations (warts) varying in size from 
that of peas to that of beans, developing later into pigeon's egg-sized, 
softish or elastic, smooth, shining, and often hemorrhagic elevations. 
Variations occur, when vesico-pustules and even large blebs form. On 
the summit the thinned epidermis commonly cracks ; the fissured apices 
later produce fungiform excrescences. The lesions may vary in number 
from one or a few to thousands, covering the entire body-surface, 
though the parts chiefly invaded are the face (especially the forehead, 
superciliary arch, eyelids, cheeks, nose, ears), the neck, and the extensor 
faces of the limbs, especially near the articulations. The palms, soles, 
and scalp are invaded more rarely, the trunk still more rarely. The 
lesions may be subcutaneous ; they may involve the mucous surfaces, 
and even the viscera. Abortive eruptive phenomena have been noted 
in cases. In some instances there is distinct confluence of lesions ; 
deep ulcerations eventually may furnish a fetid discharge, or be the 
seat of abundant hemorrhage. In such event the lesions are trans- 
formed into malignant-looking grayish or blackish spongy masses, 
covered with brownish crusts and exhaling a putrescent fetor. 

The disease may run its course in a few days or be prolonged for 
weeks or even months. The rarer complications of the general condi- 
tion are intestinal hemorrhages, hsematuria, metrorrhagia, haemoptysis, 
epileptiform convulsions, and meningitis. In favorable cases the 
eruptive elements shrivel and scale, and become the seat of varying 
degrees of pruritus which may be excessively severe. 

Etiology. — The disease is transmissible by inoculation, as evidenced 
in the case of the physician Carrion, who after self-inoculation in both 
arms from the blood of a patient, perished in fifteen days after. The 
name added to the list of titles given above is a memorial of this self- 
sacrifice. The disease attacks persons of both sexes and all ages, in- 
cluding newborn infants. Persons working in the earth are especially 
liable to contract the disorder, which seems further to be aggravated in 
conditions of moisture and warmth. Malaria is a well nigh invariable 
correlative of the affection. 



3IYC0SIS FUNG OWES. 773 

Pathology. — None of the several micro-organisms recognized in the 
disease has yet been shown to be the effective agent in its production. 
Bacilli and cocci capable of culture have been found abundantly between 
the cells and fibres of verrugous nodules, in the blood, and in miliary 
tubercles seen in the lungs and liver. 

The tissue of the nodules is of granulation type and highly vascular. 
Nicolle and Letulle found bacilli intercellular in situation, and also 
isolated in mononuclear phagocytes and in capillaries. The bacilli 
resembled tubercle-bacilli, but were somewhat larger. The walls of 
the vessels were infiltrated with leucocytes. The subcutaneous fat- 
cells, sebaceous glands, hair-pouches, and coil-glands were all infiltrated. 

Treatment. — The management of the disease is that indicated by 
the general condition of the sufferer, but all writers advise removal to 
the sea-level and a cooler climate as of the highest value. Graduated 
pressure is to be applied in the hemorrhagic cases. Tonics and stimu- 
lants are commonly needful. 

Prognosis. — The future of the individuals of the white race when 
these are attacked is more clouded than in the case of blacks. The 
prognosis is unfavorable when the eruptive symptoms decline without 
corresponding improvement in the general condition. The mortality 
is from 6 to 10 per cent, among the natives; among the whites a 
mortality of from 40 to 90 per cent, has been recorded. Death occurs 
from rapid depression due to the toxins of the disease, or to 
exhaustion or septicaemia in the cases that are prolonged. 



MYCOSIS FUNGOIDES. 

(Gr. fii'KVC, a mushroom). 

(Geanuloma Fungoides, Granuloma Sarcomatodes, Inflamma- 
tory Fungoid Neoplasm, Ulcerative Scrofuloderm, 
Eczema Tuberculatum, Fibroma Fungoides, Lympho- 
dermia Perniciosa, Sarcomatosis Generalis. Ft., Lymph- 
adenie cutanee.) 

This disease was described first in 1814 by Alibert, as "Pian fon- 
goi'de." Its symptoms resemble those of that affection, though not in 
any way related to it. 

* The" disease is uncommon ; about three hundred cases have been 
recorded in literature : l but so many of these have been observed care- 
fully and fully reported that all the "symptoms of the disorder are estab- 
lished. An attempt has been made to distinguish between two forms. 
There is, however, but one. 

Symptoms. — For convenience in description the symptoms may 

1 For further discussion of the subject, see monograph by Wolters, Bibliotheca medica, 
Abt. D. ii., H. 8, Stuttgart, 1899 (with sixteen illustrations and complete bibliography) ; 
Hvde and Montgomery, Jour. Cutan. Dis., 1899, xvii., p. 253 (bibliography) ; Galloway 
and MacLeod, Brit. Jour. Derm., 1900, xii., pp. 153 and 187 (with full histological 
report on lesions of various types taken from three cases) ; Leredde, La Pratique Derma - 
tologique, vol. iii., p. 527 (bibliography) ; Breakey, Jour. Cutan. Dis., 1902, xx., p. 316 
(autopsy and histological report) ; and Stowers, Brit. Jour. Derm., 1903, xv., p. 47 
(with recent bibliography). 



774 NEW-GROWTHS. 

be grouped roughly in three stages, which, however, do not always 
occur in regular succession, and of which the first and second may 
never be manifested. 

The so-called " Premycosic Stage " (Erythematous Period 
[Bazin], Stadium Eczematosum [Kaposi] is characterized by the 
occurrence of a series of cutaneous phenomena of different types, which 
have been described as resembling, if not identical with, eczema, lichen, 
erythema, pityriasis rubra, psoriasis, urticaria, furunculosis, and other 
congestive and inflammatory cutaneous affections. In a contribution l 
based on a personal experience in thirteen cases and a review of the 
literature of forty-eight cases in which these early phenomena were 
described, we concluded, in common with a few other investigators, 
that these early dermatoses, though differing considerably in clinical 
type, have many characteristics in common, and are, the varied ex- 
pressions of a definite morbid process. The term Prefungoid, 
employed by Morrow, would designate better this stage than the 
generally accepted term premycosic. The mischief undoubtedly is 
declared with the earliest pruritic symptoms, and the skin-eruptions in 
the early periods of mycosis should be considered as significant expres- 
sions of a general disease as the tumors themselves. 

The earliest phenomena vary greatly, and may imitate any of the 
above-named dermatoses. The most frequent lesions, however, are in 
the form of round or circinate, sharply defined, erythematous patches, 
psoriasiform plaques, or infiltrated discs, usually characterized by scal- 
ing and by itching. These areas are commonly from one to six centi- 
meters in diameter, but may be of any size, and in rare instances (as in 
one of our cases) the redness and scaling may be universal. General- 
ized vesiculation has also been noted. The lesions usually are dry ; but 
at times may be moist, crusted, or even the seat of small papules and 
vesicles. The color varies through the different shades of red, orange- 
red, or scarlet, often combined with tints of brown or purple. As the 
lesions persist thickening and infiltration of the skin are noted, and the 
patches become more sharply outlined, more distinctly circinate in 
contour, and, by extending peripherally while clearing in the centre, may 
either coalesce or begin to assume the gyrate and fantastic figures so 
characteristic of the disease. Itching is usually a pronounced feature, 
but may be absent. The course of the lesions is capricious, even more 
so than in eczema. One or all of the patches may disappear suddenly 
and spontaneously, only to return without apparent cause in old or 
new sites, and after intervals of days or months. Treatment, save by 
radiotherapy as noted below, either constitutional or local, seems to have 
almost no influence upon the course of the lesions. This stage, during 
which the patches come and go, may last a few months or several years 
(thirty, Dubreuilh) before the appearance of the more characteristic 
areas of infiltration. 

In what may be called conveniently the second stage, or Pe- 
riod of Infiltration (Lichenoid Period [Bazin, Vidal, Brocq, 
Fabre]), circinate, sharply defined, elevated plaques and nodules ap- 
pear, either in the site of previous lesions or independently of 

1 Loc. cit. 



PLATE XXVI 




Prefumgoid Stage of Mycosis Fungoides. 

i From a painting.) 



MYCOSIS FUNG OWES. lib 

them or concurrently with them. The nodules are pea-sized or 
larger ; the infiltrated plaques are button-sized to palm-sized, or 
larger, sometimes extending over the greater portion of the chest, 
back, or abdomen. The color varies from a bright pink through 
varying shades of red and occasionally of brown or violet. The sur- 
face may be smooth or verrucous, or fissured and excoriated as the 
result of scratching. The pruritus is usually severe, but may be absent. 
The shape and career of these plaques are almost, if not quite, diag- 
nostic. They are circular or circinate, as a rule, and as a result of an 
extending periphery and clearing centre they are constantly changing 
in both site and contour, often moving over the surface in gyrate bands 
or lines, or assuming half-moon, crescent, horseshoe, kidney, or other, 
often fantastic and grotesque, shapes. Again, they disappear and re- 
appear without apparent cause, as do the lesions of the first stage. 
While in many cases these variations in site and form require several 
months for completion, cases not infrequently occur in which the whole 
aspect of the disease changes in a feAV days. In one of our patients 
the lesion assumed the form of a curious network of connecting, broad, 
flat-topped ridges, between which were corresponding valleys of nor- 
mally colored and apparently normal integument. As a rule, the lesions 
on disappearing leave no trace of their previous existence, but they may 
be followed by areas of more or less permanent pigmentation or of 
vitiligo. More rarely, circumscribed areas destitute of pigment and re- 
sembling leucodermatous patches, may occur in the skin where no pre- 
ceding lesion has been observed. The symptoms of this period often 
occur with, or may be replaced by, those of the preceding stage. The 
two periods together may last many years (fourteen in one case) before 
the appearance of tumors, though in exceptional instances they may be 
preceded by tumor-formation. 

In the so-called third, or Fungoid, Stage (Mycofungoid, Neo- 
plastic Period), which, in some instances is the first and only stage, 
the characteristic Tumors of the disease appear upon the face, scalp, 
chest, and other portions of the body. They are bean- to cocoanut- 
sized, or larger ; whitish, pinkish, pale, or dull reddish in hue, sessile or 
pedunculated, well rounded or lobulated and distinctly circumscribed. 
They are covered usually, before ulcerating, with a dry scaling or 
crusted epidermis. When developing from the plaques above described 
they may be quite flat. They may spring from any of the previously 
described lesions or from the sound skin. They occur upon all parts 
of the body, upon the palmar and plantar surfaces, the arms, the fore- 
arms, the thighs, the legs, the face, and the back. Often they are in 
various degrees pigmented, showing purplish, brownish, or even black 
colors. They are usually painful, and may or may not be tender. 
The pruritic sensations of the premycosic stage may now be absent. 
When the tumors have attained maturity, and before involution has 
begun, their appearance, especially upon the face, is characteristic. 
Here they are smooth, moderately firm, globular, often lobulated, or 
sausage-shaped, of a peculiar reddish hue, and when numerous produce 
a lepra-like deformity, closing the eyes in consequence of their size or 
weight, producing the leonine brow and the elephantiasic ear. In one 



776 



NEW-GROWTHS. 



of the cases reported by us/ and illustrated in Fig. 85, the body of the 
patient was covered extensively with tumors of all sizes resembling 
those seen on the face. 

Like the other lesions of this disorder, the tumors may disappear 
spontaneously, while others appear ; or they may all disappear to return 
after uncertain intervals without known cause. As a rule, they leave 
no trace of their previous existence, though they may be followed by 
pigmentation or slight atrophy of the skin. Sooner or later some of 
the tumors degenerate, and lead to superficial ulceration, accompanied 
by adenopathy, usually followed by papillary excrescences and mush- 
room-like growths of varying sizes from which the disease obtains its 
name. At the summit of these the hairs usually fall. At times they 
may be the seat of much more destructive ulceration, though with but 

Fig. 85. 




Mycosis fungoides. 

few exceptions this destruction is limited to the new-growth, and even 
large fungoid and apparently deeply ulcerated tumors may disappear 
completely and leave no trace further than pigmentation and possibly 
a small atrophic scar. 

The general condition of the patient at first seems unaltered ; later, 
when the tumors ulcerate, exhaustion occurs and the victim usually 
dies as a result of febrile processes, of intercurrent disorders, pneumonia, 
tuberculosis, nephritis, leucocythsemia, cachexia, or pyaemia. When 
the tumors are many and ulceration extensive the appearance of the 
patient is repulsive in the extreme ; the exhalations from the body are 
in the highest degree fetid, and the difficulty of procuring asepsis, 
hygienic care, and comfort for the wretched sufferer is well-nigh insur- 
1 Edinburgh Med. Jour., 1883-1884, xxix., p. 592. 



MYCOSIS FUNGOIDES. Til 

mountable. Extirpation of the tumors usually is followed by recur- 
rence, frequently with added malignancy. 

The superficial and deep lymphatic glands may enlarge, and this 
adenopathy, as in the case of the tumors, may subside to be replaced 
later by similar involvement of the same or other glands. Other com^ 
plications of the disease are : pleuropneumonia, pulmonary tuberculosis 
hemiplegia, nephritis, and erysipelas. 

The duration of the tumor-stage is brief compared with the others ■ 
frequently death occurs within a few months, though it may be post- 
poned two or three years. 

Etiology. — The disease is more frequent in men than in women, 
often in those of unusual weight and size, and usually occurs between the 
thirtieth and fiftieth year of life, most often after the fortieth year, 
though in a few instances it began earlier, even in childhood. The 
disease bears no relation to tuberculosis, lepra, syphilis, or sarcoma ; 
and proof of its infectious or contagious character is wanting. Though 
the cause of the disease is not definitely known, there can be little 
question as to its infectious character. It is produced probably by 
specific micro-organisms, but direct evidence of contagion and success- 
ful inoculation-experiments are wanting. 

Pathology. — The disease has been studied by many observers, 
including ourselves. While the reports of different investigators at 
first reading apparently vary widely, closer study of the recorded 
observations indicates that on the main points they agree. The early 
lesions show on histological examination oedema and dilatation of the 
vessels, especially the lymph-capillaries, with often some endothelial 
proliferation, and a more or less dense cell-infiltration that is limited 
usually to the upper part of the corium, except w T here it surrounds some 
of the deeper vessels in the forms of sheaths or " cuffs." Galloway 
and McLeod l described in the early stages a connective-tissue cell- 
infiltration not only about the vessels, but also about the hair-follicles, 
the sebaceous glands, the muscles of the hair-pouch, the ducts of the 
coil-glands, and occasionally along the lymphatic spaces between 
the connective-tissue fibres. They conclude that the infiltration 
may originate in the cells of any of these structures. The infiltra- 
tion in some instances is difiuse, but sharply separated from the 
deeper parts of the corium by a horizontal line, and from the rete 
above by a narrow layer of connective tissue. In other instances the 
infiltration occurs in round or irregular areas, separated by bundles of 
normal connective tissue. Where the cells are most compact they are 
supported by a very delicate fibrous structure made up in part of elastic 
fibres. Degeneration of collagenous and elastic fibres occurs in the late, 
but not in the early, stages of the disease. The cells forming the infiltra- 
tion are in the main of the connective-tissue type, but in many cases they 
and their nuclei show the greatest diversity in size, shape, and staining 
qualities. Round, cuboidal, or irregularly shaped cells with little pro- 
toplasm and a deeply staining nucleus are numerous. Many of the 
irregular bodies are apparently fragments of cells. In many places the 
cells are packed so closely as to modify their shape and size. This mul- 
1 Brit. Jour. Derm., 1900, xii., pp. 153, 187. 



778 NEW-GROWTHS. 

tiformity of the cells is apparently characteristic of the disease, and 
Unna believes that it is due to the result of two antagonistic processes 
constantly going on, that is, cell-multiplication and cell-destruction, 
and that many of these odd forms are nothing more or less than cell- 
fragments. Mast-cells, multinuclear cells, and giant-cells are seen in 
some lesions, but are absent in others. Mitotic figures are frequent. 
The papillae are enlarged, in places packed with cells, in others more or 
less ©edematous, as also are portions of the subpapillary layer. The 
rete is everywhere hypertrophied, the interpapillary processes being 
elongated, broadened, and frequently branched. In places the cells are 
swollen and oedematous, with spaces between them. Mitotic figures 
here also are numerous, especially in the basal layers. Walters, in 
summing up the results of all investigations, justly states that no dis- 
tinctly specific changes peculiar to the disease, have been recognized. 

As the lesions progress toward the tumor-stage the cells in the 
corium become more regular in form and size, and the rete becomes 
much thinner. In the fully developed tumors the rete usually is 
reduced to a few layers of cells (sometimes but one), but in some 
instances it dips down deeply into the growth in a way to suggest epi- 
thelioma were it not that these epithelial processes are very slender. 
Many of the tumors correspond closely in structure to sarcoma, others 
show the histological formation of granulomata. 

Numerous micro-organisms have been seen in the blood and tissues, 
and some have been cultivated, but none has been demonstrated to 
have any pathogenic relation to the disease. Among them may be 
named streptococci in the capillaries of granulation-nodules, and sta- 
phylococci in cultures from blood. Other examinations of blood, of 
infected tissue, and of tumors were wholly negative as to the discovery 
of cocci. Walters agrees with other observers that the organisms 
recognized and cultivated are in general the results of secondary infec- 
tion, and bear no etiological relation to the disease. 

It is alleged that mycosis fungoides is a form of sarcoma. The facts, 
however, that fully developed tumors disappear spontaneously, and that 
in few instances has involvement of viscera been reported in mycosis 
fungoides changes in the deeper organs have been found similar to those 
which occur in leukaemia and pseudoleukemia, but no definite relations 
have been recognized between these conditions and the disease under 
consideration. There is a growing tendency among observers to class 
mycosis fungoides with the infectious granulomata. 

Diagnosis. — The age, weight, and often the protuberant abdomen 
of the patient are usually to be considered. In the early erythematous 
stages the disease is to be distinguished especially from eczema, psoria- 
sis, urticaria, erythema multiforme, and dermatitis exfoliativa. While 
a positive diagnosis cannot always be made at this time, in the 
majority of cases a careful consideration of the typical features 
just described will leave little doubt as to the nature of the 
disease. The circinate contour of the lesions, their spontaneous dis- 
appearance and reappearance, and the rebelliousness to treatment of 



MYCOSIS FUNGOIDES. 779 

what appears to be a mild and superficial inflammatory process, are 
features not found to the same extent in any of the other dermatoses 
named above. Aside from the absence of these three marked character- 
istics in psoriasis there is much more thickening of the plaques and 
there are characteristic scales, while the situation, history, and other 
features of the lesions are usually sufficient for a diagnosis ; in moist 
forms of eczema the discharge and multiformity of lesions are both 
greater than in mycosis fungoides. 

When these early lesions of mycosis fungoides appear in irregular 
patches the diagnosis from eczema can be made only after they have 
been under observation for weeks or months. In those exceptional 
cases which begin as a generalized exfoliative dermatitis an early diag- 
nosis is not possible. 

After the appearance of infiltrated plaques, or of well-developed 
tumors in case the other stages are absent, the diagnosis is usually 
clear. The infiltrated areas, nodules, and smaller tumors may at 
times closely simulate leprosy ; but the history, the absence of areas of 
anaesthesia and other characteristics of leprosy, and the histological 
examination should clear up the diagnosis without difficulty. The 
tumors are distinguished from those of sarcoma by their history and 
career, and by their final formation of characteristic fungoid, super- 
ficially ulcerating masses. 

Treatment. — We have employed radiotherapy for one year in an 
unquestioned case of prefungoid mycosis fungoides with excellent 
results. The plaques have disappeared and the patient for months at a 
time has been wholly free from the symptoms of the disease. Each 
return of those symptoms has been combated successfully by the same 
measure. Jamieson, 1 Weidenfeld, Lustgarten, 2 and Elliot 3 have each 
had a similiar experience. Observation, however, of these cases for 
nearly twenty years will be needed before one can predicate the pos- 
sibility of curing the disease by these measures. At present it can be 
said merely that the prospects of such a cure are brilliant and the 
immediate results highly satisfactory. The pruritus and complicating 
dermatoses which may be present in the early stages may be treated 
locally with various soothing, protecting, and antipruritic applications 
(see treatment of eczema) according to the indications in each case pre- 
sented. 

The comfort of the patient is to be secured by all measures, includ- 
ing anodynes in an advanced stage of the disease, and his strength 
should be supported by a generous diet and tonic regimen. Arsenic 
in full doses and by hypodermatic injection has been of apparent ser- 
vice ; Koebner reported one patient cured by this treatment. Locally 
ichthyol, bismuth oleate, and many other preparations have been of 
service in allaying the symptoms and retarding the progress of the 
disease. When the affection is generalized, tepid baths are productive 
of great comfort ; the use of boric acid, resorcin, aristol, carbolic acid, or 
some similar agent is indicated by the fetor arising from the person. The 

1 Brit. Jour. Derm., 1903, xv., p. 1. 

2 Archiv, 1903, lxvii., p. 123. 

3 Jour. Cutan. Dis., 1904, xxii., p. 185. 



780 NEW-GROWTHS. 

ulcerating masses may be protected by a wet antiseptic dressing, or 
after cleansing dusted with the zinc stearate compounds, iodoform, 
aristol, or other powder, and protected by a proper dressing. Extir- 
pation of the tumors is proper when such a course will add to the com- 
fort of the patient. 

The Prognosis is unfavorable except as it shall be modified here- 
after by radiotherapy. The patient may survive from a few months 
to a maximum of fifteen years, the average being from two to four 
years. After the development of tumors the patient may live but a 
few months or at most two or three years. Three cases of recovery 
are on record, one of the patients relieved after an attack of erysipelas. 



SARCOMA CUTIS. 

(Gr. oap% } flesh.) 

Sarcoma of the skin is a rare disorder characterized by the occur- 
rence, either as primary or as secondary developments, of single or 
multiple, pea- to egg-sized and larger, pigmented and non-pigmented, 
cutaneous and subcutaneous neoplasms having a marked inaptitude for 
ulceration but malignant in character, recurring after extirpation, and 
usually terminating fatally with involvement of the viscera. 

The term sarcoma, meaning a fleshy tumor, was employed originally 
by Virchow in the designation of this disease, and has been made to 
include conditions which undoubtedly are related more closely to the 
granulomata than to sarcoma proper. At present there is no satisfac- 
tory classification of the sarcomata and of the closely allied conditions 
which show an almost complete transition between malignant sarcoma 
on the one side and infective granuloma on the other. For conveni- 
ence the group may be divided into melanotic sarcoma, non-pigmented 
sarcoma, and sarcoid growths. 1 

Symptoms. — (A) Melanotic Sarcoma, or Melano-sarcoma. — This is 
the more common and most malignant form. It may develop from a 
pigmentary nsevus that has been irritated, or from any pigmented point 
upon the integument, especially upon the dorsum of the hands and 
feet, the lower extremities, the genital region, and the face — over the 
cheek or near the orbit, where it may originate from the choroid coat 
of the eye. In a few instances metastatic, sarcomatous deposits on the 
face have been preceded by a diffuse bluish pigmentation. 

Melanotic sarcoma may be of primary occurrence or may develop 
as a secondary deposit. The lesions are bean- to egg-sized, usually 
single or multiple, very firm or doughy, sessile or pedunculated, spher- 

1 For a full discussion of sarcoma and sarcoid, see Johnston, Jour. Cutan. Dis., 1901, 
xix., p. 305 (a careful histological study with 7 excellent photomicrographs, a review 
of the subject, a proposed classification based on pathological findings, and bibliography), 
and Ibid., 1903, xxi., p. 23 (a case of fibro-sarcoma) ; and Pini, Bibliotheca Medica, 
Abt. D. ii., Heft 9, Stuttgart, 1901 (bibliography). On Sarcoma, De Amicis, Trans. 
Twelfth Internat. Cong. Med., Moscow, 1897 (abstr. in Brit. Jour. Derm., 1897, ix., 
p. 440) ; and Fordyce, Morrow's System, vol. iii., p. 670. See also special references 
under Sarcoid Growths. 



SARCOMA CUTIS. 781 

oid or tabulated ; and varying in color from grayish brown to inky 
blackness. The epidermis may be discolored, thinned, and intact, or 
be ulcerated. The nodules are often surrounded by blackish puncta 
which eventually develop into tubercles. The lesion or lesions may 
for a long time remain stationary, or they may rapidly be followed 
by generalization, as a result of local irritation, either by extension 
from a central point to adjacent tissue, or by transmission through the 
lymphatics to a distance from the primary nodule. 

In a case lately observed by us the left lower extremity of a middle- 
aged woman was studded with split-pea-sized to marble-sized, ink-black 
masses from the ankle to the middle of the thigh. The larger were 
always centres of groups of similar pinhead-sized black nodules. The 
skin of the region affected was swollen, inextensible, inelastic, and as 
firm as sole-leather. The disease had extended from the ankle upward 
in the course of a few months. 

Melanotic sarcoma is one of the most malignant and rapidly fatal 
of all neoplasms. Therapy is usually unavailing ; and the prognosis 
is grave indeed, a fatal result usually occurring with rapidity after the 
occurrence of generalization, and commonly with visceral complications 
by reason of secondary deposits. 

Recent studies of Unna, Gilchrist, 1 Schalek, 2 and others 3 indicate 
that malignant growths arising from pigmented moles are usually (if 
not always) carcinomatous rather than sarcomatous. 

Melanotic Whitlow (Hutchinson) is described as a chronic ony- 
chia, displaying pigmented spots, suggesting silver-nitrate stains at the 
edge of the nail-fold, where eventually a fungus tumor forms with 
increase of pigment until the nail is exfoliated, and the process becomes 
generalized. 

(B) Primary Non-melanotic Sarcoma. — This occurs in both localized 
and generalized forms. 

The localized variety of primary non-melanotic sarcoma is rare, and 
is seen chiefly in women. As in other sarcomata, it is often first recog- 
nized at a point where a nasvus or other warty growth has become irri- 
tated, usually on the extremities. At such a point there forms a firm, 
dull-whitish nodule, having nearly the hue of the normal skin, rarely 
vascularized, that may, after persistence without change for a variable 
period, break down by ulceration and become the seat of a fungous 
vegetation. Generalization of the process may result either spontane- 
ously or from accidental complications. 

The disease, when affecting the skin in multiple lesions, is character- 
ized by the appearance of several, usually at first isolated, pea- to nut- 
sized and larger, smooth, spherical, irregular, or tabulated cutaneous or 
subcutaneous tumors. They may or may not at first be attached to the 

1 Jour. Cutan. Dis., 1899, xvii., p. 117 (investigation of two cases and of several 
pigmented moles ; bibliography). 

2 Jour. Cutan. Dis., 1900, xviii., p. 145 (histological study of five cases, with review 
of literature) . 

3 Cf. Whitehead, Johns Hopkins Hosp. Bull., 1900, xi., p. 221 (two cases, with 
review of literature) ; and Whitfield, Brit. Jour. Derm., 1900, xii., p. 267 (two cases, 
with references). 



782 NEW-GROWTHS. 

epidermis above and to the deeper structure beneath, but they eventually 
contract such adhesions. Between them the skin may not be involved. 
In uncomplicated cases at this period the conspicuous features of these 
lesions are : (a) their whitish color, due to envelopment in an unaltered 
epidermis ; (b) the history of a relatively rapid development, as distin- 
guished from fibromata, epitheliomata, gummata, and lupous tubercles, 
(c) the speedily declared systemic results of the growth. 

Later, the skin between the lesions becomes swollen, infiltrated, 
painful ; and, even before the tubercles desquamate, enormous tume- 
faction and redness of an erysipelatous type may affect the.internodular 
tissue. In this way an entire limb, only one portion of w T hich is the 
seat of tubercular growth, may attain an elephantiasic size, ulcerate at 
one or more points, and pour out an offensive secretion as a consequence 
of ulceration of the inflamed integument. 

The disease is both rapid in course and malignant in type. In a 
few weeks or months the nodules or tumors of sarcoma coalesce, degen- 
erate by ulceration, and participate in the process going on in the in- 
flamed and excoriated skin where they are implanted. Death results 
either from exhaustion, intercurrent fever, or sarcomatous involvement 
of one or of several viscera. By the same process the skin-lesions may 
be the product of metastasis from the lymphatic glands or the viscera. 

The disease occurs in this form over the chest, the extremities, and 
the genitalia, though all parts of the skin have been invaded. 

Recurrent Fibroid of the Skin (Hutchinson), beginning usually 
in the lower extremities, and tending to slow extension, to rapid and 
persistent recurrence, and to ulceration and formation of fungous tumors, 
with ultimate marasmus, is set down by Crocker as a rare form of 
spindle-cell sarcoma. 

(C) Sarcoid Growths. — Under the head of " sarcoid tumors " Kaposi 
included as a temporary classification, Granuloma (Mycosis) fungoides, 
Idiopathic multiple pigment-sarcoma, Sarcomatosis cutis, and Multiple 
benign sarcoid. The first of this group, Mycosis fungoides, is con- 
sidered in this work in a separate section. 

Idiopathic Multiple Pigment-sarcoma 1 (of Kaposi and others 
owes its coloring to cutaneous hemorrhages and not to a pigment-de- 
posit. It occurs chiefly in male subjects (from forty to sixty years of 
age) who have been laborers, whose hands and feet become the seat of 
an oedema, accompanied by pruritus and other subjective sensations. 
Later, brownish, bluish-red, or dark-purplish spots appear, out of 
which develop pinhead- to pea-sized nodules, gradually increasing in 
volume, discrete, tender, and often grouped. They may be the seat of 
lancinating and radiating pains. As they multiply a lardaceous infil- 
tration progressively involves the depth of the integument, until an 
elephantiasic condition is produced, a hand, a foot, or an entire limb 
becoming of cartilaginous hardness, bluish in tint, and covered with a 

1 Some recent literature: Sellei, Monatshefte, 1900, xxxi., p. 413 (bibliography) ; 
Sequeira-Bulloch, Brit. Jour. Derm., 1901, xiii., p. 201 (bibliography and colored plate) ; 
Bernhardt, Archiv, 1902, lxii., p. 237 (bibliography), and Ibid., lxiii., p. 239 (2 plates) ; 
Koehler and Johnston, Jour. Cutan. Dis., 1902, xx., p. 5 ; Sellei, Archiv, 1903, lxvi., p. 
41 (with plate and bibliography). 



SARCOMA CUTIS. 783 

smooth, mammillated, squamous, or, rugous envelope, which may be 
also the site of tumors of considerable size. These tumors are fewer in 
number and smaller in volume as they spread from the distal to the 
proximal parts of the limb. They may be sessile, pedunculated, and 
grouped, but they are always of a deep-bluish or violaceous tint. 

These growths may remain for a long time stationary ; or they may 
be entirely resolved, the patient apparently securing complete recovery. 
Very rarely they ulcerate or exhibit slight erosions. At times they 
are covered with or surrounded by telangiectases, or by tissue exhibit- 
ing infiltration of blood. When the mucous membranes are involved, 
points, patches, disks, or infiltrations of a dusky-reddish or a bluish 
shade appear on the inner side of the gums, the lips, the tonsils, or over 
the palate ; and there is visceral involvement with lymphatic and 
vascular changes. The usual signs of physical exhaustion ensue, with 
fever, dysenteric symptoms, haemoptysis, and marasmus. The disease 
may last only from three to five years, but a duration of fourteen years 
has been recorded. Post mortem tumors have usually been recognized 
in the viscera. Only a few infantile cases have been recorded. 

Remarkable instances of complete recovery from this affection are 
multiplying. A patient with the hands completely relieved was shown 
at the International Dermatological Congress in London, in the year 
1896, Kaposi having verified the diagnosis. A patient rapidly recov- 
ering from the same disorder is under our observation. It is doubtful 
if this condition be a true sarcoma — in the sense in which this term is 
generally accepted. 

Sarcomatosis Cutis. 1 — In this disorder, which occurs chiefly in 
people of middle age, multiple nodules appear deep in the corium or 
subcutaneous tissue. The tumors are not defined sharply, but shade 
gradually into the surrounding tissue. Careful palpation reveals be- 
ginning nodules over which the skin is neither prominent nor discol- 
ored. The color of the tumors, at first that of the normal integument, 
assumes a reddish tint, which becomes deeper in shade with the age of 
the tumors. The lesions may coalesce to form raised irregular plaques 
or masses similar to those seen in mycosis fungoides. There is no in- 
volvement of the lymph-nodes. The tumors may disappear spontane- 
ously or break down and form punched-out ulcers or fungous masses. 

Multiple Benign Sarcoid (of Boeck). — The following summary 
of Boeck's original article is an excellent description of the disorder. 

" Clinically, we find in a middle-aged, pale, thin man, groups of lymph- 
nodes much swollen, and on examination a slight augmentation of the 
number of white corpuscles. At the same time there exists a wide- 
spread, somewhat symmetrical eruption, firm nodules of varying size, 
on the head and extensor surfaces of trunk and extremities. They range 
in size from a hemp-seed to a bean, and the larger have irregular con- 
tours. They involve the whole skin and are movable with it. Only 

1 Kecent literature: Fendt, Arcbiv, 1900, liii., p. 213 (with bibliography); Pini, 
loc. cit., and Archiv, 1902, lxi., p. 103 (report of a case, with illustrations and refer- 
ences) ; Pelagatti, Monatshefte, 1902, xxxv., p. 249 (with bibliography) ; and Wende, 
Jour. Cutan. Dis., 1903, xxi., p. 307 (with discussion before the American Derm. Assoc, 
regarding the relation of sarcoid growths to leucsemic tumors, and to the granulomata). 
See also references under Sarcoma. 



784 NEW-GROWTHS. 

on the scalp is the infiltration not palpable. Here only yellowish out- 
lines are seen. The color of the early nodules is bright-red, becoming 
darker and finally yellowish or brown. Slight scaling occurs on older 
lesions. They show a tendency to peripheral spreading and central 
depression. On the face they have a peculiar appearance, with blue 
centre and yellow border, a feature present in all cases that I have 
seen. The nodules disappear finally, leaving as a rule a loss of sub- 
stance in the skin, which may be white on the face, yellow on the 
back, and darker at the periphery on the legs. Exudation and ulcera- 
tion never take place. A papular eruption grouped like lichen planus 
was seen on the inside of the thigh. A tendency to develop at the 
site of an old injury should be remembered. The symmetry is not 
such as is found in affections whose localization is evidently determined 
by central nerve influence. The disease seems to be benign, and dis- 
appears under arsenic or perhaps spontaneously." * 

Multiple cutaneous and subcutaneous tumors are reported of occur- 
rence in leukaemia and pseudoleukemia. Some of these are apparently 
sarcomatous in nature while others evidently should be classed with 
mycosis fungoides. 

The Etiology of the sarcoma group of disorders is unknown. Ac- 
cording to Babes, sarcomata are frequently congenital, and are found not 
rarely in early youth upon the eyelids, the extremities, and the geni- 
talia. A belief in the parasitic origin of some, if not all, of the sar- 
coma group is entertained by some observers. Jurgens, 2 L. Loeb, 3 and 
others have grafted bits of sarcoma into the tissues of rabbits, rats, and 
mice, and produced tumors identical pathologically with sarcoma. Loeb 
transplanted sarcoma in this way through a number of generations. 

Pathology. — Sarcoma of the skin may be primary, but is probably 
more often secondary to the disease in deeper organs of the body. His- 
tologically, it is a connective-tissue growth, made up largely of round- 
or spindle-cells, and corresponds closely to the structure of sarcoma in 
other parts of the body, the spindle-cell being somewhat more frequent 
than the round-cell type. Other mixed types, as fibro-sarcoma, angio- 
sarcoma, or lympho-sarcoma, are seen occasionally. The most com- 
mon type recorded is melanotic sarcoma, which has been described as 
developing from pigmented moles or warts. Recent investigations of 
Unna, Gilchrist, 4 Schalek, 5 and others prove that some, probably the 
majority, of these growths have their origin in epithelial cells, and 
should therefore be classed with carcinoma. Kromayer 6 believes the 
epithelial cells undergo transformation into connective tissue, and Loeb 7 
has shown that such a change may take place when epithelial cells are 
transplanted into connective tissue. 

1 Literature: Boeck, Jour. Cutan. Dis., 1899, xvii., p. 543, and Kaposi's Festschrift, 
1900 ; Hallopeau and Eck, Annales, 1903, s. 4, iv., p. 251 ; Gottheil, Jour. Cutan. Dis., 
1902, xx., p. 400 (with bibliography) ; Rasch and Gregersen, Archiv, 1903, lxiv., p. 337. 
See also references under Sarcoma. 

2 Centralbl. f. Chirurgie, 1896. 

3 Jour. Med. Eesch., 1902, viii., p. 44. 

4 Loc. cit. 5 Loc. cit. 

6 Zeitschrift, 1896, iii., p. 263. 

7 An experimental study of the transformation of epithelium to connective tissue, 
W. W. Warren, 1899, 



SARCOMA CUTIS. 



785 



Fig. 




In the so-called " idiopathic multiple pigment-sarcoma " of Kaposi 
the pigmentation is due entirely to hemorrhage and the blood-slowing 
which follows. The growth is highly vascular, containing many newly 
formed vessels, the walls of which are very thin and often are made up 
of the cells of the tumor, The cells are spindle-shaped and the tumors 
are situated deeply in the cutis or in the subcutaneous tissue. In the 
older lesions there may be endothelial proliferation. Involution occurs 
through destruction and resorption 
of the tumor-cells and pigment, and 
the organization of fibrous tissue. 
Observers differ as to the pro- 
priety of classing the condition as 
a sarcoma or as a granuloma. 

Fordyce 1 describes several cases 
of localized angio-sarcoma of the 
skin in which the single tumor was 
identical histologically with the 
generalized sarcoma of Kaposi. 

In sarcomatosis cutis the growth, 
according to Fendt, is composed of 
large round cells, which in some 
tumors are encapsulated and in 
others diffused through the cutis. 
Where the infiltration is diffuse 
the collagen disappears, though the 
elastic fibres are unmodified. At 
the centre of the nodules the cells 

undergo degeneration and lose their staining power. Necrosis of the 
nodule may occur, producing an abscess, which discharges through a 
small opening in the integument. 

In benign sarcoma the following histological changes are described 
by Boeck : " The areas of new-growth might be described as peri- 
vascular sarcomatoid tissue built up by excessively rapid proliferation 
of epithelioid connective-tissue cells in the perivascular lymph-spaces, 
with little addition of other varieties. The tumor soon begins to 
degenerate and the tissue is rarefied, showing a network of branched 
connective-tissue cells. It should be remembered that true giant-cells 
of sarcomatous type were found, though rarely. Compared with 
other new growths of the skin, this must be said histologically to 
possess affinity to sarcoma, and also to the very rare cases of so-called 
pseudoleukemia cutis described by Arning and Max Joseph. The 
new-growth here described, nevertheless, seems at present to be rather 
sui geyieris. It should be emphasized particularly how different the 
histology of this process is from that of leukaemia cutis, with its 
lymphoid tissue and small lymphoid cells. " 

The Diagnosis rests upon the history, symptoms, and microscopical 
examination of the new-growth. Sarcoma should not be confounded 
with fibroma, epithelioma, gumma, or lupous nodules. 

1 Amer. Jour. Med. Sci., 1900, cxx., p. 159. 
50 



Sarcoma: spindle-cells visible in sections of 
cutaneous nodule removed from a sarcomatous 
patient. (About X 300.) 



786 NEW-GROWTHS. 

Treatment of sarcoma is unsatisfactory. Surgical ablation of these 
tumors is apt to be followed by their speedy return.' 

Koebner's injections of arsenic (usually Fowler's solution, 2 to 4 
drops in 1 to 2 parts of distilled water, repeated every second day for 
months, with gradual increase of the dose) seem to have proved suc- 
cessful in two cases. 1 Wende 2 reports a case improving under this 
treatment. Arsenic, potash, and ergot, internally ; and salol, cam- 
phorated naphtol, aristol, and bismuth subnitrate, locally, have secured 
only transitory benefit. Successful results, but also several deaths, 
are reported from inoculation with cultures of Streptococcus of 
erysipelas. Favorable results have been reported in a few instances 
by Coley and others from injection of the combined toxins of this 
streptococcus and of Bacillus prodigiosus. In the majority of cases 
these measures are unsuccessful. Pusey, 3 Coley, 4 and others report 
favorable results with the a>rays. With this agent they have suc- 
ceeded in relieving pain, and in a few instances in causing a disappear- 
ance of the tumors. In a case of glioma in a child which had recurred 
twice after operation, we succeeded with the arrays in preventing a 
recurrence of the growth after a third operation by Dr. Noble. 

The sarcoid growths may disappear spontaneously or under pro- 
longed treatment with arsenic, but in the majority of cases they pro- 
gress slowly through a number of years to a fatal termination. 

The Prognosis in sarcoma is unfavorable, a fatal issue occurring in 
most cases. 

CARCINOMA. 5 

(Gr. napKivog, cancer. ) 

The term cancer has been employed both loosely and definitely in 
the designation of malignant cutaneous tumors. Every cancer of the 
skin is, according to some authors, necessarily both alveolar and epithe- 
liomatous in structure; while others distinctly recognize forms of cancer 
which are not epithelial. In these pages, for the sake of retaining a 
convenient clinical distinction, the term carcinoma, or cancer, is limited 
to malignant growths of epithelial origin. 

EPITHELIOMA. 

(Epithelial Cancer, Carcinoma Epitheliale, Rodent Ulcer. 
Ger., Epithelialkrebs ; Fr., Cancroide.) 

Symptoms. — Three clinical varieties of epithelioma are recognized 
— the superficial, the deep, and the papillary. They are practically no 
more than varying phases of a single pathological process. 

1 Berlin, klin. Woch., 1883, xx, p. 21. 

2 Jour. Cutan. and Gen.-Urin. Dis., 1898, xvi., p. 205. 

3 The Rontgen Ravs in Therapeutics. 

4 Med. News, 1902, lxxxi., p. 542. 

5 For further consideration of cutaneous carcinoma, see discussion before the Ameri- 
can Dermatological Association, Trans., 1900, p. 110, and Jour. Cutan. Dis., 1900, xviii., 
p. 366 ; and Darier, La Pratique Derma tologique, ii., p. 395. 



PLATE XXVIII. 








lib, N*ai 

■»«£,' » El - m: t£ sam 

H£ IB v '« 

Bv v Mil 


fu* ■ $%?' tK^ 








Clinical Varieties of Cutaneous Carcinoma. 



CARCINOMA. 787 

Superficial, or Discoid, Epithelioma usually is displayed first upon the 
sound skin in the form of one or of several pinhead-sized papules, flat 
infiltrations, disks, or nodosities of a dull-yellowish, reddish, grayish, 
or dirty wax-like hue. The growth may also have its origin in pre- 
viously existing skin-lesions which are both numerous and different 
from one another. Among the latter symptoms may be named : fissures 
and excoriations (especially those long teased by caustic applications) ; 
warts, nsevi, acneiform and molluscoid lesions ; and the dry or greasy 
epidermal scales often seen at the orifices of sebaceous glands in the 
faces of the aged. The outline of the newly developed growth as a 
consequence varies, being roundish, linear, or irregular. As a result of 
accident or traumatism (especially scratching and picking, which the 
history of a large proportion of all cases includes) there forms a super- 
ficial excoriation, which may be covered with a sero-sanguineous crust 
after the desiccation of its scanty and ichorous secretion. In the prog- 
ress of its development it is often noticed that new foci of disease appear 
in the immediate vicinity of the first, represented by subepidermic 
indurated nodules, or superficial "pearls" resembling milia, whitish and 
lustrous, with marked tendency to vascularization, exfoliation, and 
superficial ulceration. 

Rodent Ulcer 1 (Jacob's Ulcer, Ulcus Exedens, Noli-me- 
Tangere, Cancroid Ulcer). — The characteristics of this form of 
superficial epithelioma are a roundish, fissured, or slightly angular con- 
tour, and a reddish or reddish -brown, irregular, granulating, and mam- 
millated floor, covered with a thin, translucent, viscid serum, which, in 
drying, suggests the effect of a varnish over the part. The edges of 
the ulcer are clean cut, indurated, everted, usually well attached, and, 
seen in horizontal profile, irregularly indented. The symptoms are 
slight at first ; the lymphatic ganglia and general health being unim- 
paired. Its site of election is the face, particularly the eyelids, nose, 
temples, and lips, though the genitalia, the hands, and the feet may be 
affected. Of two hundred and fifty cases collated by Heurtaux, in one 
hundred and ninety the face was attacked. 

Some English writers still describe the rodent ulcer as distinct from 
epithelioma, chiefly by reason of its individual peculiarities. Patho- 
logically no distinction can be established between the two. The clin- 
ical features upon which this distinction is based are : the slow or 
intermittent development of rodent ulcer ; its tendency to destroy, as 
it extends, all the tissues within reach ; its failure to implicate the 
system by secondary deposits or metastases ; its rounded and often 
widely everted edges, or, better, lip, often distinctly vascularized ; its 
gouged floor exhibiting unequal levels ; its slight tendency to granula- 
tion ; and its feeble or negative attempts at repair. All these symp- 
toms are those of epithelioma, if one chooses to employ that term in its 
large and proper sense. The rounded or oval excavation, often exceed- 
ingly clean cut, at times with a corded and whitish rim, producing, 
little, if any, pain, is characteristic of the rodent ulcer, yet in its exten- 
sion it may exhibit all the symptoms of a deep epithelioma. 

1 For full discussion of this type of epithelioma, see Dubreuilh et Anche, Annales, 
1901, s. 4., ii., pp. 705-780 (seventeen figures; bibliography). 



788 NEW-GROWTHS. 

Under the title " Crateriform Ulcer/' Hutchinson l describes a form 
of epithelioma distinguished chiefly by rapidity of invasion. Its 
onset is by the formation of a roundish or conical mass which rapidly 
exhibits ulceration, a central crater forming with exceedingly dense 
walls. 

The subsequent course of the lesion varies, its evolution being gen- 
erally slow and accomplished in years. Sometimes having attained a 
maximum of size, the ulcer, if unmolested, long persists without appre- 
ciable change. In other cases the base cicatrizes and the epithelioma 
completely exfoliates, leaving an outlying linear ulceration which may 
persist or spread. In yet other cases, after a persistence of from ten to 
twenty years, the ulcer may spontaneously close and the disease be at 
an end. Sometimes the ulceration is very superficial and slowly 
spreads in circles, segments of circles, or in irregular gyrate outlines, 
the older portions healing and cicatrizing while the border advances. 
Such lesions may cover considerable areas of the body and closely 
resemble the serpiginous lesions of syphilis and lupus. In many 
cases the papillomatous element is marked. To this form of super- 
ficial discoid epithelioma the name Paget's Disease is sometimes 
applied, as the process is practically the same as that which attacks 
the nipple and breast. Finally, any one of the destructive and malig- 
nant cancerous processes may be awakened, and the epithelioma be 
thus transformed from the type of the superficial to that of the deep 
variety of the disease. 

Deep, or Tubercular, Epithelioma. — This variety may originate in the 
manner already described, or may be from the first characterized by 
its specific features. It commonly begins by the formation of round- 
ish, very firm, pea-sized nodosities closely set in the skin and subcu- 
taneous connective tissue, or be thus situated and well projected from 
the surface. In the course of months and years these nodules develop 
to form a nut- or even a small egg-sized tumor, roundish, dark reddish 
in color, and delicately vascular on its surface. This tumor may be 
a deep flattish or globoid development within the skin ; or be a well- 
defined nodule attached to it ; or (and this is a common form) be a 
dense, thick, flattened plaque, a centimetre or more in diameter, its 
walls steeply descending to the sound skin on either hand or mode- 
rately everted ; its centre depressed by atrophic changes ; its surface 
shining, waxy, pinkish, or red, with ramifying capillaries. " Satellites" 
may form in its vicinity. 

Degeneration of these forms produces in the course of time an ulcer 
either like that described above, or one which deeply and destructively 
encroaches upon the tissues beneath. In advanced cases the latter 
ulcer is irregular in contour, with a clean-cut, everted, indurated lip ; 
eroded and "gouged," hemorrhagic and granulating floor; thin, viscid 
secretion which is foul and purulent at times when the resulting destruc- 
tion is rapidly accomplished ; and a deep attached base which may be 
perforated by a crateriform ex ulceration extending down to or through 
muscles, fasciae, cartilage, and bone. The lymphatic ganglia become 
simultaneously involved, and a general cachectic condition is established. 
1 Transactions London Pathological Society, 1889, p. 275. 



PLATE XXIX, 



Fig. 1, 




Multiple Carcinomata, with Diffuse Pre-eaneerous Hyperkeratosis. 



Fig. 2. 




Section from a Small Tumor from the same patient. 



CARCINOMA. 789 

Death may ensue from marasmus, exhaustion, or hemorrhage in the 
course of several months or from one to three years. 

Papillary Epithelioma. — The cancer in this variety assumes the form 
of a malignant papilloma. In these cases a pedunculated or sessile, 
narrow or broad-based, smooth-capped, or spongy and verrucous vege- 
tation is attached to the skin upon Avhich it forms. It may originally 
be as small as a pea, but usually it increases considerably in volume, 
being not rarely pigeonVegg- and turkey Vegg-sized. The surface is 
either dry, reddish yellow, smooth, and lustrous ; exfoliating, and se- 
creting an offensively smelling sanguineous or translucent fluid ; or is 
moist, granulating, filamentous, and intermingled with hairs, as when 
it occurs upon the bearded cheek. Degeneration occurs later, fissures 
forming first ; subsequently there appear superficial, and finally deep, 
ulcers which ultimately assume all the features of the epithelioma 
described above. 

In some cases the epithelioma forms a soft, hemispherical, small 
nut- to egg-sized tumor, which upon pressure discharges numerous 
convoluted plugs, composed of epithelium, fatty masses, and a purulent 
secretion. The bases of these soft masses are remarkable for the ease 
with which they can be curetted and thus radically removed. 

A careful study of well-marked cases of papillary epithelioma indi- 
cates clearly that while ulceration often results, the centre of the mass 
breaking down and furnishing a typical cancerous excavation, with 
hard and rounded or oval border, uneven base, irregular granulating 
floor, and offensive discharge, the picture may be wholly different. 
Occasionally the superficial process extends widely over the brows, 
cheeks, and chin, interspersed with raised cicatriform areas, suggesting 
that ineffectual attempts had been made to check the disease by sur- 
gical measures. These apparently atrophic disks, mingled with vas- 
cular, florid, fungiform, pyriform, and oddly shaped outgrowths, are 
really cancerous infiltrations of the type of discoid epithelioma. They 
may be seen gluing the lobe of the ear to the cheek, or everting the 
lower lid, even when superficial papillary vegetations are the predomi- 
nant features of the disease. 

Epithelioma of the skin occurs also with multiform features, almost 
as numerous as the several different lesions from which a cutaneous 
cancer may take its origin. 1 Thus, a wart, a "button," a vegetation, a 
crack, an erosion, may result in a fissure that bleeds easily and refuses 
to heal. After months or years there forms an epithelioma, assignable 
to one of the clinical varieties described above. In other cases there 
may be a number of greasy scales upon the skin-surface resembling 
those seen in well-marked seborrhcea sicca ; and in one or two spots 
the removal of these scales offers to the eye a superficial erosion 
implicating the derma, bleeding freely, and, when undisturbed, crusting 
and slowly spreading under the crust rather than healing. In yet 
other cases a thin pellicle of apparently loosened epithelium, looking 
like a papery crust, is found, when removed, to cover three or more 

1 Cf. Fordyce : " Clinical and Pathological Observations on some Early Forms of 
Epithelioma of the Skin," N. Y. Med. Jour., June 9 and 23, 1900. 



790 NEW-GROWTHS. 

shallow ulcers, unexpected and hidden from view by the tenacious 
pellicle which had protected them and beneath which they had indo- 
lently and painlessly developed. 

These varieties or types of epithelioma may coexist in different por- 
tions of the same integument, or the one may develop from the other, 
a malignant papillary growth springing from a superficial or a deep 
cancerous infiltration. Familiar examples of the disease are seen upon 
the eyelids and contiguous portions of the nose ; the cheek and the 
lower eyelid, the latter being often drawn into ectropion by a cicatri- 
form bridle or band ; the nose or lip and adjacent mucous or osseous 
tissue ; and the glans and prepuce where the vegetating forms are of 
more frequent occurrence. The vast destruction wrought by the widest 
development and consequent degeneration of epithelioma is sufficiently 
recorded in the annals of both medicine and surgery. A woman sixty- 
four years of age was exhibited at the clinic, in the centre of whose 
face an ulcerating epithelioma had left a wide chasm, after destroying 
three-fourths of the nose and upper lip, and the hard palate with all 
the upper teeth and the antrum. The bones at the base of the skull 
were exposed. This case illustrated well the occasional remarkable 
tolerance by the system of the profoundest encroachments of epithe- 
lioma. She was then digesting and assimilating food with fair profit, 
and suffered chiefly from pain. She did not die until several months 
had elapsed, and then only as the result of hemorrhage from an ulcer- 
ative opening into one of the large arteries. 

Cancer of the Head. — In this region of the body nearly three- 
fourths of all cancers of the skin are recognized. Upon the brow, 
the alse of the nose, the temples, cheeks, chin, scalp, or other part, the 
disease may begin either upon or beneath entirely normal skin, or in 
that which has pathologically been changed. The origin of the disease 
is usually ascribed to the picking, scratching, or shaving over a seba- 
ceous wart in an old man ; or in similar traumatisms of acneiform, 
seborrhceic, or furuncular lesions in either sex. In other cases the der- 
matologist, consulted with reference to some other ailment of the skin, 
can recognize, in persons of the age most liable to such accidents, one 
or several pinhead-sized or larger milium-like nodules, clustered about 
the temples or the nose, that indicate the site of the awakened epithe- 
liomatous change. The disease progresses slowly, spreading super- 
ficially along the alse of the nose in irregular lines, in more complete 
centrifugal outline over the temple and brow ; almost symmetrically 
over the tip of the nose, and with odd indentations of contour in the 
dense integument immediately in front of the tragus of the ear. The 
vegetating forms are more common on the brow, scalp, and chin ; the 
" rodent-ulcer " type, over the temples and cheeks. The more super- 
ficial varieties in any part of the face may slowly be converted into the 
deeper. The flattened, egg-sized disks of infiltration are more common 
on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more con- 
spicuous than in the face. Cartilage, bone, muscle, and entire organs 
melt before its ravages with astounding readiness. Within a period of 
two years a circumscribed flat epitheliomatous infiltration, limited for 



CARCINOMA. 791 

many months to one cheek, may spread to the point of destroying the 
ear, eye, and inferior maxilla of one side of the face, opening into the 
larynx and oesophagus, and not producing a fatal result until the jugular 
vein of the same side is opened by ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women on account of the tobacco-habits of the former, may arise either 
as a minute lobule or as a circumscribed thickening on or near the 
vermilion border, usually of one side, or as a linear, narrow, and shal- 
low excoriation, often protected by a thin crust, extending well along 
the mucous edge of the lower lip that is in contact with the upper 
when the two are lightly approximated. Later, the lip may be the 
seat of a defined tumor, small nut- to egg-sized, that may deeply in- 
volve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla, and 
eventually produce one of the formidable and remediless chasms of the 
lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon 
more frequently than to the dermatologist. The glans penis, the 
clitoris, and the prepuce are occasionally the seat of a warty variety ; 
but the scrotum, labia, thighs, mons veneris, and abdominal walls, as 
w r ell as the parts first named, may be involved in the superficial or the 
deep form of cancer. In persons of cleanly habits the superficial 
variety of epithelioma may persist in the genital region as indolent and 
innocuous as upon the face; but where filth is permitted to accumulate 
about the part (lochial, menstrual, catarrhal secretions ; pus, urine, 
feces, etc.) the spread may relatively be rapid. The ulcer is then deep, 
seated upon an indurated and very tender base, and has the steep, 
punched edge and hemorrhagic floor of the rodent ulcer. Ulceration 
may, later, open the rectum, vagina, corpora cavernosa, perineum, and 
deep perineal fascia, resulting in vast destruction that proves fatal by 
exhaustion of the forces of the aged patient. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually papillomatous, or of the flat, superficial form. 
It may appear upon the left hand of right-handed patients. Its prog- 
ress is indolent, and when properly treated is much less liable to grave 
ulceration than epitheliomata in other situations. In special regions, 
especially on the lower extremity, where the force of gravity generally 
aggravates any ulcerative process, there may result caries, necrosis, 
fistules, loss of phalanges, etc. 

Cancer of the Mucous Surfaces may be primary or be second- 
ary in origin. The mucous lining of the oral and nasal cavities, of the 
vagina, the rectum, and the balano-preputial sac may thus be involved, 
either by extension of the disease from the neighboring cutaneous sur- 
face or by primary involvement of the mucous tissue. The most 
important, by reason of statistical frequency, is cancer of the tongue 
and buccal membrane, often having its origin in the leucoplasic stria- 
tums, plaques, or thickenings, known as " smokers' patches/ 7 ichthyosis 
linguae, psoriasis linguae, etc. A pinhead- to pea- or bean-sized super- 
ficial excoriation is usually the first lesion to which attention is attracted, 
reddish in color, granulating, tender, and not often very painful ; or the 



792 NEW-GROWTHS. 

beginning is a shallow fissure at the edge or on the tip of the tongue or 
on the mucous face of the lower lip, its long axis commonly at right 
angles to that of the organ upon which it forms. Beneath with more 
or less rapidity (as a rule slowly) dense induration occurs, lancinating 
pains dart from the affected region toward the ear or along the jaw, the 
submaxillary and other glands become tumid and tender, deglutition pain- 
ful and in severe cases well-nigh impossible ; or from the nasal membrane 
the disease extends toward the palate, pharynx, or larynx, ulceration, 
when it occurs, opening up a vast chasm which represents all these 
cavities. In the vagina and the rectum a cancerous change may begin 
with merely a thickening of the surface of the mucous membrane lead- 
ing in the course of time to a superficial and later to a deep ulcerative 
process ; or, as in cutaneous epithelioma, the papillary form may be repre- 
sented in vegetations, cauliflower-shaped, filiform, or simply warty and 
mammillated, that eventually degenerate and furnish the most formida- 
ble of destructive results. 

Etiology of Epithelioma. 1 — The essential causes of cancer are 
unknown, though there can be no question that mechanical, chemical, 
and other local irritations are often immediate excitants of its patho- 
logical processes in the predisposed skin. In this way the excoriations, 
warts, nsevi, and other lesions named above, though not in themselves 
cancerous, may become the original sites of the disease. In this way, 
too, the irritation produced upon the lips of the smoker by his pipe or 
tobacco ; the local disorder about the inner canthus of the eye result- 
ing from occlusion of the lachrymal ducts ; the frequent teasing by 
caustic or other substances of the wart on an old man's hand ; and 
other agencies disturbing the balance between waste and repair, aided 
at times by senile atrophic changes, may result in the development of 
an epithelioma. The danger of malignant changes in certain forms of 
keratoses, 2 especially in later life, is recognized generally. The long- 
continued use of arsenic may be followed by hyperkeratosis and epithe- 
lioma. 3 

The possibility of the transmission of cancer by heredity has almost 
ceased to obtain credence in the light of modern pathology, yet Broca 
reports sixteen deaths from cancer in one family, and Friederich a con- 
genital epithelioma in the child of a cancerous woman. 

The disease is eminently one of advanced life, being most frequent 
after the fortieth year, and a pathological curiosity in childhood. 
Kaposi reports one case at the tenth year. Only about 30 per cent, 
of all cutaneous cases occur in women, a fact possibly explained by the 
relative infrequency of the action of local irritants in those who are 
not subjected to the exposures incidental to the trades and laborious 
occupations of life. These figures, however, relate only to cancer of 
the skin, since,, when cases of cancer of the breast and of the uterus 

1 Literature on the etiology and pathology of cutaneous carcinoma : Hartzell, Jour. 
Cutan. Dis., 1900, xviii., p. 435 ; Fordyce, N. Y. Med. Jour., 1900, also cited on p. 789, 
and Schiitz, Archiv, 1902, lxii., p. 91 (bibliography). . ■ , P , A 

2 Of. Hartzell, Jour. Cutan. Dis., 1903, xxii., p. 393 (discussion before the American 
Dermatological Association; bibliography). 

2 Gf. Darier, Annales, 1902, s. 4, iii., p. 1121 (references to literature). 



CARCINOMA. 



793 



are included, the proportion of the sexes affected is almost exactly 
reversed. 

In favor of the local origin of cutaneous epithelioma is the clinical 
fact of the excellent general health of most patients in the earliest 
stages of the malady. The theory that carcinoma is due to a specific 
parasite, and is therefore infectious and contagious, is gaining ground. 
No parasite has yet been demonstrated, since the protozoa-like bodies 
which Darier and others described in cancer-cells have been demon- 
strated to be forms of cell-degeneration. 1 




Epithelioma (vertical section) : a, d, cones of the rete projecting downward, between these 
are seen atrophied papillae (b) ; at e, d, and other points are " nests " of epithelium ; c, atrophied 
stratum corneum. (After Kaposi.) 

Pathology. — All epitheliomata have their origin in preexisting 
epithelium. The old idea that they originated from connective tissue 
has been disproved. The essential feature of all forms of epithelioma 
is proliferation of epithelium and its growth into the deeper tissues, 
where it is not normally found and where its presence causes secondary 
inflammatory changes. Two pathological types of epithelioma are of 
interest to the dermatologist, the lobulated and the tubular. 

In the Lobulated form the interpapillary processes of the rete send 
down prolongations which subdivide and branch in all directions, the 
branches intercommunicating and giving off buds and processes which 
may form new centres of growth. The origin of tije growth may be 
traced to the interpapillary processes or to the epithelium of the seba- 
ceous glands, coil-glands, or hair-follicles ; but more frequently the 
source cannot be determined absolutely, since the band connecting the 
growth with its starting-point may have been destroyed by ulceration. 
On the other hand, the glands and follicles may be involved second- 
arily. Attempts have been made to classify epitheliomata according to 
the structure from which each originates, but there seems to be no good 
ground either clinical or pathological for such distinction. The branch- 
ing processes form variously shaped lobules, and the cells composing 
them assume, as the result of pressure, many shapes. Usually, how- 

1 Cf. second report of cancer committee to the Surgical Department of Harvard 
Medical School, Jour. Med. Resch., 1902, vii., pp. 235-380 (illustrations and bibli- 
ography) ; and Zieler, Archiv, 1902, lxii., pp. 3 and 370 (bibliography). 



794 NEW-GROWTHS. 

ever, the outer layer of a lobule is a row of cylindrical cells within 
which are cuboidal prickle-cells, which toward the centre are under- 
going cornification, the centre itself being composed of horny stratified 
cells. Thus, the structure of a lobule from without inward corresponds 
closely with that of the normal epidermis from within outward. Some- 
times the prickle-cells within the lobules show no tendency to cornifica- 
tion. In places the lobules are compressed into globular masses having 
concentric layers like an onion. These bodies are the epithelial " nests/' 
" globes/' or " pearls." The centre of such nests not infrequently shows 
colloid, fatty, or granular changes. In rare instances calcification of 
the lobule occurs. 

The connective tissue of the part into which the growth has pene- 
trated surrounds and supports the lobules, and may remain almost nor- 
mal, or be thickened and infiltrated with round cells, or its fibres may 
be mixed with epithelial cells ; it contains blood-vessels, none of which 
penetrates the lobules. In some cases the epithelial growth proves 
greatly irritating to the surrounding tissues, exciting in them marked 
inflammatory processes. Fordyce believes the inflammation may be 
due in part to a pus-infection, and in one case, by using Gram's method, 
he demonstrated staphylococci in the inflamed tissue. 

In the Tubular variety of epithelioma the epithelial elements form 
freely anastomosing, cylindrical processes which extend vertically, 
horizontally, and at various angles through the cutis and often into the 
subcutaneous tissue. The cells are smaller than in the lobular variety 
and do not, as a rule, undergo cornification or form " nests." The 
outer row of cells may be cylindrical and stain deeply, and as the tubu- 
lar processes may assume shapes highly suggestive of gland -formation, 
this variety of epithelioma is supposed by some observers always to 
originate in the epithelium of a coil- or sebaceous gland. Largely 
owing to the ease and rapidity with which the starting-point or con- 
necting-band may be destroyed by ulceration, it is often impossible to 
demonstrate the origin of the processes, but the investigations of 
Darier, Pollitzer, Fordyce, and others have led to the belief that the 
growth originates rarely in the sebaceous glands, but frequently in the 
rete or in the epithelium of the coil-glands and hair-follicles. 

Tubular epitheliomata are, as a rule, less malignant and less rapid 
in their course than are those of the lobular type. Transitional forms 
are seen, however, which tend to show that the shape and mode of de- 
velopment of the processes depend as much upon the accident of loca- 
tion and surrounding tissue as upon the character of the epithelium 
from which they originate. Rodent ulcer — which some authors de- 
scribe Under a separate head — is pathologically a tubular epithelioma. 

Diagnosis. — Epithelioma is to be distinguished from lupus vulgaris 
approximately by the age of the patient, the latter disease rarely 
appearing after the thirty-fifth year where there is no scar or a history 
of its earlier existence. Lupus is, at an earlier period of its career, 
more diffuse than epithelioma ; its elementary forms are more dis- 
tinctly groups of individual lesions than a homogeneous aggregation ; 
its ulcers are more often bordered by outlying non-ulcerative papules ; 
furnish a more puriform discharge ; and, most distinctive of all, are 
never walled about by the firm, densely indurated, often everted lip 



CARCINOMA. 795 

of the epithelioinatous ulcer, usually opening upon a sound peripheral 
integument. The peculiar and often characteristic odor of the cancer- 
discharge is absent in lupus. 

From syphilis, epithelioma is to be distinguished : first, by the age 
of the patient, syphilis being decidedly a disease of early and middle 
life ; second, by the far greater relative rapidity of the syphilitic pro- 
cess, exception always being made of tertiary gummatous ulcers upon 
the lower extremities persisting for years when there are both lack of 
internal treatment and of local support ; third, by the history of the 
disease in each particular case ; and, fourth, by the characteristic 
syphilitic features always present in infected individuals, including 
multiplicity of lesions, typical cicatrices, contour of ulcers (that of 
epithelioma is less often either reniform, horseshoe-shaped, or cres- 
centic), character of discharge, and general absence of pain. A very 
important point to note is a marked tendency to reparative cicatriza- 
tion in old syphilitic ulcers, partly due to exhaustion of the infec- 
tive poison, partly to the influence of an insufficient but yet modifying 
treatment. This tendency is exceedingly rare in epithelioma, which is 
often, while syphilis is rarely, a malignant disease. 

Epithelioma of the genitals is not to be confounded with chancre, 
gumma, or syphilitic tubercles of that region. The peculiarities of the 
consequent adenopathy in each case ; the lancinating pains of cancer ; 
its much more prolonged duration ; and its occurrence in an aged subject, 
with the general history of the case, will usually point to the truth. 

Sarcoma is characterized by its far more rapid evolution, the tumors 
often attaining their maximum of development in the course of a few 
months ; by its occurrence by predilection in earlier life ; by its inapti- 
tude for ulcerative degeneration ; and by its marked tendency to multi- 
plication in contiguous or in distant portions of the body. 

The warts, nsevi, excoriations, and seborrhceic lesions, from which 
epitheliomata often take their origin, cannot be determined as having 
such a tendency before the cancer has attained some development. 
Every such persistent and long-irritated lesion on the person of a male 
subject of advanced years should be regarded with suspicion. 

Treatment. — No internal treatment for cancer of the skin is known 
to exert the slightest influence upon the growth. 

The topical treatment of epithelioma is by excision, erasion, or 
destruction of the growth. The first is performed by surgical ablation 
with a bistoury, after which one of the plastic operations may be 
required for either complete covering of the wound or relief of the 
resulting deformity. The second is applicable only to the less for- 
midable growths, and is performed with the aid of a dermal curette. 
The third is effected by the use of caustics. The removal of smaller 
epitheliomata, of the face especially, with the aid of a dermal curette, 
should generally be followed by the thorough application of the milder 
caustics, such as silver nitrate in crayon. 

Since Stenbeck, in 1899, exhibited a patient from whom he had 
removed a rodent ulcer by the use of the arrays, 1 the value of the 

1 Cf. Pusey, The Kontgen Kays in Therapeutics ; Williams, The Kontgen Kays in 
Medicine and Surgery ; Freund, Grundriss der Gesammten Kadiotherapie, Vienna, 1903 ; 
Allen, Jour. Cutan. Dis., 1903, xxi., p. 75; Sequeira, Brit. Med. Jour., June 6, 1903; 
Hyde, Montgomery, and Ormsby, Jour. Amer. Med. Assoc, January 3, 1903. 



796 NEW-GROWTHS. 

method in certain types of cutaneous carcinoma has been established 
by the reports of a large number of observers. 

Of 125 patients having deep-seated or superficial cutaneous carci- 
noma with whom we have given the treatment satisfactory trial, 102 
are free from their disease. Of these, 76 have remained well for six 
months or more ; 50 for a year or more ; 32 for eighteen months or 
more, and 15 for more than two years. Two only of the 102 patients 
have exhibited a recurrence of the disease, which in both instances was 
slight and yielded readily to further treatment. In 16 cases the lesions 
were superficial, and in the early stages of transformation from pre- 
epitheliomatous hyperkeratosis into malignant growths. There were 
also 2 cases of Paget' s disease of the nipple. The majority of the 
cases were of the rodent-ulcer type, involving the skin and more or 
less of the deeper structures. 

Of the 23 patients not cured, 13 presented inoperable, deeply seated, 
practically hopeless cases of carcinoma, involving the mouth, throat, 
breast, rectum, or uterus. In these and in other deep-seated carci- 
nomata we have found that the treatment lessened pain, and in some 
instances retarded the growth temporarily. Two patients dismissed 
temporarily when nearly well have not reported final results. Five 
cases of deep-seated rodent ulcer, with distinctly indurated borders, are 
yet under observation, having shown decided improvement, but only 
after much treatment during a considerable period of time. In 3 cases 
of deep-seated carcinoma of the lip and cheek the growth increased 
rapidly under treatment. 

We have had no failures in the treatment of superficial epithelioma 
with the a>rays, some of them disappearing after five or six exposures. 
Of 17 carcinomas of the lower lip, 15 were removed entirely by the 
use of the #-rays, but the majority of the lesions were superficial, and 
all were more resistant to treatment than lesions of the same type situ- 
ated upon the skin. In two deeper-seated tumors of the lower lip, for 
which the patients had refused operation, the growth, though arrested 
at first, eventually developed with great rapidity. 

In the 102 cases in which satisfactory results were obtained, the 
average number of treatments for a given case was fifteen. Treat- 
ments were given, as a rule, daily, or on alternate days. The average 
time consumed during treatment and recovery was two months. With 
the surrounding tissues properly protected with lead, exposures were 
made with a medium hard tube, its quality, however, varying with the 
depth of the growth. The distance of the target from the lesion varied 
from four to ten inches. The time occupied for .each exposure was 
three to ten minutes. Treatment was suspended usually on the first 
appearance of reaction, and resumed, when necessary, after the latter 
had subsided. 

The chief advantages of radiotherapy lie in its painless application 
and excellent cosmetic results. It should be the method of choice in 
all superficial cases which, owing to location or to large areas involved, 
could not be treated surgically without conspicuous disfigurement. The 
treatment is of special value in diffused hyperkeratoses and senile 
skins showing beginning malignant changes. For practically all super- 
ficial lesions the method is satisfactory, but for circumscribed lesions 



CARCINOMA. 797 

more time is required than in simple excision. In deep-seated tumors, 
though radiotherapy is often successful if the growth be fully ex- 
posed to the surface, it is better to remove surgically as much of the 
tumor as possible and follow with the x-rays. In deep-seated lesions 
beneath the unbroken integument, and especially those situated about 
the neck, we have had no success whatever further than relieving pain 
and temporarily retarding the growth. In 3 deep-seated rodent ulcers 
we believe that the growth of the tumor and development of metastases 
were encouraged by the inflammatory reaction produced by the x-rays. 

Destruction of smaller cancerous tumors of the skin may be per- 
formed with the aid of caustics, of which potassium hydroxide, in stick 
or in solution, is perhaps the most valuable, as its destructive action 
may be controlled by the topical employment of acids, and it is fol- 
lowed by less pain than are some of the other chemical agents. Other 
caustic substances employed for a similar purpose are : zinc chloride, 
Vienna paste, silver nitrate, arsenical paste, resorcin, fuchsin, and pyro- 
gallol. The latter is highly recommended by Kaposi, not only because 
its application is unproductive of pain, but also because it does not 
attack sound tissue. It is used in an ointment of 10 per cent, strength. 
All such pastes and ointments should be spread upon cloths, and be 
applied for from three to six days. Opiates may be required, in the 
case of several of these agents, to relieve the consequent pain. 

Among the formulae used for caustic purposes are the following : 



R Creasoti, ^ss; 15 

Acid, arsenios., gr. iv; 

Opii pulv., gr. ij 



26 

13 M. 



Sig. For employment upon circumscribed surfaces. [Kaposi.] 

Marsden's paste, also employed as a caustic, is made by combining 
equal parts of gum arabic and arsenious acid with water sufficient to 
make a softish- paste. By Robinson l it is preferred to others, and is 
applied on rubber plaster. 

Cosine's paste, as modified by Hebra, is prepared as follows : 

R Acid, arsenios., gr. vj ; 140 

Hydrarg. sulphuret. rub., 3ss ; 2 

Unguent, aq. ros., ^ss ; 151 M. 

Sig. Arsenical paste for external use, with caution. 

The method of its application is as follows : the paste is spread over 
a thin sheet of lint to the thickness of a knife-blade, and the lint is then 
cut to a shape and size corresponding with those of the tumor or ulcer 
to be destroyed. After its close apposition with the surface cO be 
attacked the lint and paste should be covered with gutta-percha or 
other impermeable tissue, and a compress laid over the whole. In 
twenty-four hours the dressing is removed, the parts washed clean, and 
the same application renewed. By the third or the fourth day the 
destruction of the cancerous growth is usually complete, and the parts 
are ready for an emollient poultice, which should be applied for the 

1 " Treatment of Cutaneous Malignant Epitheliomata," Internat. Jour, of Surgery, 
1892, p. 179. 



798 NEW-GROWTHS. 

three or four days during which separation of the slough occurs. 
The simple ulcer left is to be treated on general principles. The 
danger of arsenical poisoning is here reduced to a minimum ; the treat- 
ment being very effectual where patients consent to the delay as to time 
and to the severe pain which it occasions. 

The thermo- and galvano-cautery may also be often advantageously 
used for destruction of the growths. The advantages of the thermo- 
cautery are : the transitory character of the induced pain ; the coal-like 
dressing left upon the attacked surface ; and the elegance of the result- 
ing scar. Both measures find their highest value when employed after 
incision or erasion. 

Whatever method be employed, thoroughness is essential in attack- 
ing all portions of the new-growth ; and it is well to encroach some- 
what upon the unaffected contiguous structure. The subsequent dress- 
ings should be made with simple or carbolated unguents, to which one 
of the salts of morphine may be added in case of continuous pain. 
The eschar usually separates in the course of a few days, leaving a 
simple granulating wound which may soundly cicatrize, and the 
epithelioma be thus radically relieved. In other cases the disease reap- 
pears in the ulcer or. cicatrix, or, by recurrence of cancerous nodules, in 
the previously sound integument. Even after these recurrences 
prompt destruction of the new-growth may finally be successful. 

But little confidence is placed upon any external treatment which 
does not effect complete destruction of the neoplasm. Yet there are 
those who highly esteem some of the procedures which are less radical 
in their aim, and which it is proper to mention here. 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large 
success in the treatment of epithelioma by potassium chlorate. Locally, 
the part is frequently touched with a saturated solution of the salt in 
glycerin and warm water, after which a simple ointment-dressing is 
applied. Vidal administers also the same drug internally in doses of 
1 J drachms (6.) in syrup and water before meals. It is possible that 
any remedial effect obtained from such measures should be attributed 
to the fomentations employed. Latterly, benzole and pyoktanin-blue 
have been reported as valuable topical applications to small-sized 
epitheliomata. 

Injections of solutions containing cupric sulphate, iodine, alcohol, 
acetic acid, silver nitrate, sodium chloride, and hydrochloric acid 
have been practised, it is claimed, with some success ; certainly at 
times with fatal results. This method is unquestionably inferior to 
others described above. 

Prognosis. — In general, the prognosis of cutaneous cancer is grave. 
The relative degree of gravity largely will be proportioned to the variety, 
form, size, career, and complications of the growth in each case. The 
variety in which only " pearls " form in the skin is the most benign, 
as the lesions are usually isolated, and may, when unirritated, undergo 
spontaneous exfoliation. In other cases the disorder for from fifteen 
to twenty years seems to make no progress of any sort. The malignity 

1 Glasgow Med. Jour., 1881. 2 Loc. cit. 

3 Bull. Acad, de Med., Paris, 1873. * These de Paris, 1877, 






CARCINOMA. 799 

of a cancerous growth is usually proportioned to the quantity of epi- 
thelium as compared with the connective tissue present ; the more 
abundant the latter, the more favorable the prognosis. Naturally, also, 
the deeper and the more destructive the growth, the fewer are the 
chances of ultimate recovery. Excessive pain and adenopathy are 
unfavorable symptoms in any case. Koch l gives statistics of the 
results of operations, at the Erlangen Clinic, for the removal of 
epitheliomata of the lower lip, in one hundred and thirty-one patients 
exhibiting primary lesions. One hundred and fifteen of these were 
for the time "cured"; four had speedy relapse; and three were, at 
the date of writing, suffering from recurrence of the disease. 

PAGET'S DISEASE. 2 

(ECZEMATOID EPITHELIOMATOSIS OF THE NlPPLE, MALIGNANT 

Papillary Dermatitis, Cutaneous Psorospermosis.) 

This disorder was first described in 1874, by Paget, 3 and has since 
attracted the special attention of a number of English, French, and 
American observers, including Thin, Duhring, Malassez, Darier, Wick- 
ham, and others. 

At the onset the disease suggests an eczematous involvement of the 
areola of the nipple, usually of one breast only, in women between 
forty and sixty years of age. According to Besnier and Doyon, the 
earliest change is without question a choking of the lacunae of the 
nipple with corneous cells, and this either without the operation of any 
known cause or as a consequence of a localized eczema, a galactorrhea, 
or other irritant. When early recognized the surface is intensely red 
and granulating, exuding copiously a clear viscid secretion, and pro- 
ducing subjective sensations of heat and burning, with intense or with 
moderate itching. The definition is distinct, the tissue is indurated, 
and the tenderness and pain are usually well marked and distressing. 
A conspicuous feature of the disease is the circumscribed infiltration 
of the skin and subcutaneous tissue, which on palpation suggests a 
large-sized coin or button let into the substance of the areola and sur- 
rounding parts. 

When the disease has progressed to this point a cancerous infiltra- 
tion of the breast is usually recognized, at least after its removal, 
though even with great care it may not always be possible to distin- 
guish it before ablation of the gland. Crocker, however, holds to the 
belief that the disease of the nipple may endure for years without 
resulting retraction and development of scirrhus of the breast. The 
French recognize three stages, that in which the disease is limited, re- 
spectively, to the nipple, the areola, and the breast, the latter, of course, 
succeeding but not replacing the earlier. In all cases there is no at- 
tempt at repair ; and when abandoned to its course the ultimate result, 
after five to eight or more years, is a profound ulceration with destruc- 
tive effects most noticeable in the region of primary invasion, the entire 

1 Centralbl. f. Chir., 1881, viii., p. 635. 

2 For bibliography, see Matzenauer, Monatshefte, 1902, xxxv., p. 205. 

3 St. Bartholomew's Hospital Reports, 1874, p. 87. See also the paragraphs in this 
treatise devoted to this subject under the title of Eczema. 



800 NEW-GROWTHS. 

breast having become cancerous. Cases of Paget's disease affecting 
other parts of the body have been reported. In such cases the process 
is identical with that of superficial discoid epithelioma described on a 
preceding page. 

Pathology. — Darier and Wickham, in a series of papers published 
during 1889 and 1890, attempted to show that this disorder was to be 
included in a list of morbid processes which they described under the 
title of " Psorospermosis/' a group of affections of parasitic origin. But 
later investigations have shown that the so-called " psorosperms " are 
in fact simple alterations of epithelium that may be recognized in other 
affections as well as in Paget's disease of the nipple. 

In the earlier stages the histopathology is that of a chronic derma- 
titis. Epithelial proliferation and thickening progress, however, and 
in the later stages the structure is that of a discoid epithelioma. 

Diagnosis. — There are few cases in which the raw and exuding sur- 
face may be mistaken for an eczema. The latter, when occurring upon 
the surface of the breast and of the nipple, is far more common during 
earlier periods of womanhood than after the fortieth year, and is seen 
chiefly among those giving the breast to sucklings. Eczema is never, 
under any circumstances, capable of producing in this region the 
characteristic button- or large-coin -sized induration beneath the deep- 
red, raw, granulating surface of the cancerous infiltration. 

The Treatment of Paget's disease should always have in view the 
possibility of cancerous involvement of the gland that usually occurs, 
though a number of cases are on record in which relief by other than 
radical measures was secured. Caustics should never be employed ; all 
irritants are to be avoided. Soothing applications, as in corresponding 
stages of eczema, the pastes, zinc and calamin lotions, diachylon and 
other soothing salves, are indicated and often prove serviceable. The 
employment of parasiticides meets with little favor now that the psoro- 
spermosis theory of the disease is abandoned. Mercurial lotions fol- 
lowed by powders of aristol or hydronaphtol (1 : 100), and a weak 
ointment of pyrogallol or of iodoform are also extolled. The arrays are 
indicated both before and after the appearance of malignant changes, and 
if used early should give relief. If the carcinomatous changes extend 
deeply beneath the skin, ablation of the entire part should be practised. 

The Prognosis is not always grave. Cases are reported as relieved 
by local measures, which are always worth a judicious trial ; but inef- 
fectual measures may permit involvement of the breast eventually call- 
ing for ablation of the entire gland. 

CANCER OF THE CONNECTIVE TISSUE. 

This is rare as a primary cutaneous manifestation, but appears gen- 
erally as secondary to a cancerous involvement of other organs, as of 
the female breast. It is termed also Scirrhous, Hard, Fibrous, or 
Lenticular Cancer. It occurs either upon the skin covering a 
breast which has previously been transformed into a cancerous mass, 
or as a cutaneous relapsing lesion after extirpation of the latter. Its 
symptoms are pea- to bean-sized, densely firm, shining nodules, vary- 
ing in color ; or a more or less diffuse infiltration of the skin, of similar 



CARCINOMA, 



801 



characteristic hardness, associated often with hyperemia of a purplish- 
red shade. 

Cancer en Cuirasse. — When the cancerous infiltration is widely dif- 
fused and densely indurated, involving a large portion of the integu- 
ment of the thorax, the condition is termed by the French cancer en 
cuirasse (Fig. 88), a title first given by Velpeau. The malady is 
striking in its peculiarities, and in the highest degree serious. The 
integument of a large portion of the chest, usually more in front, but 
also behind, and even a part of the anterior abdominal wall, is con- 
verted into a dense, leathery envelope, often so compressing the chest- 
wall as seriously to impede respiration. The edges of the infiltration 
are poorly defined save at the lines where tongue-like prolongations 
(languettes) of dull-reddish hue indicate the advance of the scirrhous 

Fig. 88. 




Cancer en cuirasse, chiefly involving the right side of the chest. 



process over the skin. The lymphatic circulation is obstructed, the 
glands enlarge, and, what is almost pathognomonic of the disorder, the 
upper extremity, especially the forearm, usually of the side chiefly in- 
volved, becomes enormously swollen and cedematous. The nipple may 
or may not be retracted ; the breasts, one or both, are firmly bound down 
to the chest-wall by the cuirass of dense skin, hard, smooth or rough, 
shining, and either reddened in dull hues or of normal tint, here and 
there traversed by vessels, and breaking down into ulcerations, usually 
first about the nipple, but also elsewhere. The process is one of the more 
rapid of the scirrhous metamorphoses of the body, as a fatal result is 
usually reached in a few months, though years have in some cases 
elapsed before death resulted. One of our patients, an unmarried woman 
with breasts in the virgin state, perished in the course of a few months, 
51 



802 NEW-GROWTHS. 

the cancer having originated in the skin. Milium-like masses, as large 
as grains of wheat, undergoing fatty degeneration in the centre and 
readily expressed like comedones, are occasionally present. 

We have had several cases of this disorder under observation, two 
being made the subject of a paper, 1 with illustrations of the clinical 
appearances, and morbid condition of the tissue. Two of the patients 
were men. An instance of widely disseminated lenticular cancer of 
the skin (illustrated by portrait), described by Morrow, 2 occurred in a 
healthy-looking woman as a secondary phenomenon after removal of 
primary cancer of the breast. Whether the nodules be, as to cutaneous 
manifestations, primary or secondary, the symptoms are generally the 
same. The lesions are closely set, shining, firm, reddish papules, infil- 
trations of a dull-reddish hue, miliary and pigmented deposits, tubercles 
varying in size, subcutaneous nodules, and secondary results in the way 
of formidable ulcers, crusts, and fungous growths. 

The prognosis is serious. In cases which are too extensive for opera- 
tion the #-ray should be used, as it usually relieves the pain and retards 
the progress of the disease, while in a number of instances it has 
caused a disappearance of the lesions. 

Pathologically, the several forms of carcinoma above described are 
epitheliomatous, since the fibrous stroma always contains, in the centre 
of narrow alveoli, a relatively small number of epithelial bodies. The 
growth is usually slow of development, but in the end is accompanied, 
as are other cancerous tumors, by adenopathy, pain, and ulcerative 
changes, which induce an inevitable cachexia. As with the other varie- 
ties, relapse after extirpation is common, and the prognosis is propor- 
tionately grave. 

Tuberose Carcinoma is a rare manifestation of the disease, occur- 
ring in the form of multiple, firm, peanut- or egg-sized, roundish nodules, 
which break down by ulcerative processes into deep losses of tissue. It 
is frequently accompanied or followed by cancerous involvement of 
other organs. It occurs chiefly upon the face, hands, arms, and chest, 
though also upon other portions of the skin of persons of advanced 
years, either as a primary or a secondary cancerous manifestation. 
Gurnard 3 reports a cancer of this variety, remarkable for the smallness 
of the existing nodules, which varied in size from that of a hempseed 
to that of a pea. They covered the entire thorax, the back, and the 
right arm ; and had here and there broken down into ulcers. One of 
the latter was as large as the hand. 

Melanotic or Pigmented Carcinoma is that form in which both 
the epithelium and connective-tissue framework of the cancer are richly 
supplied with blood-vessels, and, probably, as a consequence of trans- 
udation from the latter, with an abundance of pigment-granules in 
groups and clusters. These growths usually begin as hempseed- to 

1 Amer. Jour. Med. Sci., 1892, ciii., p. 235. 

2 Jour. Cutan. Dis., 1884, ii., p. 1. 

3 Union Med., 1881, xxxi., p. 205. 



CARCINOMA. 803 

pea-sized, single or numerous, soft or dense nodules, which may develop 
in time into tumors of considerable size, and which are stained in 
various shades from a grayish-browii or a slate color to a dead black, 
the pigment being occasionally displayed irregularly in streaks or bands 
over the surface of the growth. They occur over any portion of the 
surface, often upon the extremities and the genitals, starting frequently 
from benign pigmentary lesions, such as nsevi and moles. Anatomically, 
the pigment is found to be deposited both between the cells and in the 
protoplasm of the cells themselves. 

In a few instances the disease is limited to single melanotic growths 
of this character. The cancer is apt to develop into the papillary form, 
furnishing thus fungoid vegetations which have a noteworthy tendency 
to degenerate into ulcers. Often such verrucous masses are seen sur- 
rounded by grayish or blackish papules, or by a diffuse cancerous 
infiltration of the integument ; they also exhibit irregular pigmentation 
of the surface. The disease often appears in the viscera, in the form of 
disseminated cancerous nodules, each highly vascular, and exhibiting 
in varying quantity granules of pigment. The growth has usually a 
relatively rapid course and malignant career. Relapses are frequent, 
the amount of pigment usually increasing with each relapse. 

Recent investigations (Gf. melanotic sarcoma) indicate that the 
majority if not all of the malignant pigmented growths which spring 
from moles and nsevi, and which in the past have been considered to be 
sarcomatous, are in fact instances of pigmented carcinoma. 

Endothelioma of the skin has been reported in a few cases. 1 In 
the three cases reported by Spiegler, 2 and in the three cases collected 
by him from literature, numerous tumors, varying in size from a pin to 
an orange, were located on the scalp. In some of the cases pea-sized 
tumors were seen also upon the face, neck, back, and chest. The course 
of the growths was comparatively benign. In Fordyce's case 3 a pea- 
sized tumor formed at the border of a lupous scar on the forearm. The 
histological structure of these growths is that of a small-cell epithe- 
lioma, except that the cells are grouped about dilated blood-spaces, and 
their origin from the endothelium of the blood-vessels can be demon- 
strated. 

1 For bibliography, see Waldheim, Archiv, 1902, lx., p. 225. 

2 Archiv, 1899, 1., p. 163. 

3 Amer. Jour. Med. Sci.. 1900, cxx., p. 159. 



CLASS VII. 
SENSORY DERMATO-NEUROSES 



A large number of skin-diseases are more or less dependent on 
neuropathic conditions, and could probably be classed as sensory, motor, 
vasomotor, or trophic dermato-neuroses. Morris 1 and Leloir, 2 and a 
few others attempt such a classification ; but in the large majority of 
these dermatoses the neuropathic element is not so well understood as 
are some other features according to which most authors classify these 
affections. In this chapter are considered only the sensory dermato- 
neuroses, that is, those disorders in which there is disturbance of sensation 
without other recognized changes in the skin. 

These purely sensory dermato-neuroses are commonly described under 
four headings : hyperesthesia, anesthesia, dermatalgia, and paresthesia 
(including pruritus). 

Bronson 3 calls attention to the fact that cutaneous sensation is complex 
and made up of a number of elements which he describes as common 
sensation (or mere subjective feeling), including the sense of pain ; the 
sense of temperature ; the sense of touch, including the pressure-sense 
and the sense of contact ; and a special sense of a higher order, which 
is exercised in feeling for or of a definite object, and which he terms 
the sense of Pselaphegia. This sense includes and is dependent 
upon the preceding elements, and is ranked with the special senses of 
seeing, hearing, and smelling. Any one of the above-named senses 
may be exaggerated, defective, or perverted, while the others remain 
normal, or all may be involved simultaneously. 

HYPERESTHESIA. 

(Gr. vTrep, above ; cuo&qtjis, sensibility. ) 

Hyperesthesia is an exaggerated sensitiveness to external impressions. 
In this condition the abnormal sensations are aroused by contact with 
an external body, and do not arise spontaneously, as in dermatalgia 
and in paresthesia. The distinction between these conditions may 
often be difficult to recognize, since two or more of them may coexist ; 
or the hyperesthesia may be so excessive that the slightest unrecognized 
current of air is sufficient to produce a marked sensation. Finally, in 
some forms of hyperesthesia abnormal sensations may result from 
irritation due to mental or emotional causes. It is evident that this 



Diseases of the Skin, London, 1898, 

Twentieth Century Practice, vol. v., p. 749. 

Morrow's System, vol. iii., p. 725; and N. Y. Med. Kecord, Oct. 18, 1890. 

805 



806 SENSORY DERMATO-NEUROSES. 

last type of hyperesthesia can be differentiated with difficulty, if at all, 
from paresthesia. 

Cutaneous sensation may be exaggerated as a whole, but the senses 
most commonly involved are those of contact and common sensation, 
including the sense of pain. In mild cases there is merely an unusual 
sensitiveness to contact with foreign bodies, such as the clothing, but 
in severer forms the light touch of a feather or slight currents of air 
over the skin may be almost intolerable. In the condition known as 
Hyperalgesia the sense of pain is greatly exaggerated, while the 
sense of touch is diminished. As a result, the slightest contact with 
an object causes great pain, but the nature of the object causing the 
pain is not recognized so distinctly as in health. In some instances it 
is the temperature-sense alone that is involved, as a result of which 
the surface is exceedingly sensitive to cold, or, more rarely, to heat. 

Hyperesthesia, involving one or all of the senses mentioned above, 
may be mild or severe, and may be limited to very small areas, as in 
tabes or leprosy ; to certain regions or to one side of the body, as in 
hysteria ; or it may include the entire surface, as in disease of the 
cord, in neurasthenia, and in other disorders of the nervous system. 

The causes of hyperesthesia are found in various functional and 
organic disorders, central or peripheral, of the nervous system. 

In connection with the hyperesthesie may be mentioned a condition 
which cannot be considered pathological in itself, though it is often 
dependent upon pathological states. Reference is made to the unusual 
development and acuity of the touch-perception, or sense of pselaphegia, 
as a result of which contact with a foreign body gives the perceptive 
centres a more delicate and complete impression of that body than 
would normally be obtained. This unusual sensitiveness of the touch- 
perception is seen frequently in the blind, and may even be cultivated. 
It occurs also in the hypnotic state ; in intoxication from alcohol, or 
from cannabis indica ; in hysteria and some other mental and nervous 
disorders ; and in conjunction with the other forms of hyperesthesia. 

Treatment is that of the nervous disorder upon which the hyper- 
esthesia depends. 

DERMATALGIA. 

(Neuralgia Cutis.) 

In this morbid state the integument becomes the seat of painful 
sensations, which may or may not be associated with a hyperesthetic 
condition. This disorder is much more frequently partial than general, 
being in the larger number of cases a local expression of some disease 
of the nervous centres or tracts. It is observed usually in middle life, 
and in women more than in men. Its symptoms vary in severity from 
a slight burning to a state of torture that defies description. In charac- 
ter the pain is differently described as comparable to that produced by 
friction, incision, penetration, contusion, or burning of the integument, 
as also to the passage over the part of streams of very hot or of cold 
water, or the electric current. With this there is commonly associated 
an undue sensitiveness to contact with foreign bodies. The skin pre- 
sents no objective signs of disease. The disordered sensations may be 



HYPERESTHESIA. 807 

limited to the scalp, the region of the spine, or the palmar and plantar 
surfaces. In the latter situation it is often significant of some ob- 
scurely developed systemic disease, such as syphilis, rheumatism, or 
locomotor ataxia. In a middle-aged woman a persistent dermatalgia 
of the interscapular region was associated with confirmed gastric dys- 
pepsia. In other cases the disorder is dependent upon disturbance of 
the uterine function. It is occasionally observed as one of the rare 
signals of the occurrence of the menopause. 

It is to be noted that the severe dermatalgia associated with dis- 
orders of the uterus in women is occasionally succeeded by a cutaneous 
lesion. In a middle-aged dysmenorrhceic patient under observation a 
pea-sized hemorrhagic bulla appeared over the forehead after several 
weeks of frontal suffering. Buck 1 also reports dermatalgia of the 
brows and wrists in a young woman who had frequently miscarried, 
followed by recurrent formation of a vesicle which accomplished its 
career of rupture, crusting, and erosion in a stadium of from five to 
seven days. 

Diagnosis. — The disease is to be differentiated from hyperesthesia 
of the skin, with which it frequently is associated and from which it 
often cannot be distinguished with certainty, as it is not possible always 
to exclude slight sources of external irritation ; and further the diagnosis 
must be based largely upon the observations and statements of the 
patient. Painful affections of deeper parts, muscular, nervous, apo- 
neurotic, and visceral, must also be excluded. Severe pain limited 
strictly to the skin of the lumbar region, with hyperesthesia, may pre- 
cede the occurrence of perinephritic abscess. 

The Treatment is to be directed to the disorder of which, in the 
great majority of cases, the dermatalgia is merely a local symptom. 
Quinine, the salicylates, iron, arsenic, and zinc phosphide are often 
indicated. Temporary relief, however, may be afforded by the local 
application of a rubber bag filled with very hot or very cold water ; 
sometimes by an alternation of the two, each for a few moments at a 
time. Sponging the part with very hot water is also useful, continued 
for longer periods, and followed by swathing in cotton-batting covered 
with Lister protective. In some cases the anodynes also may be used 
topically with advantage ; especially cocaine, opium, aconite, belladonna, 
or stramonium in oily combinations. In some cases relief is had by 
painting the parts with SquiblVs mercuric oleate and morphine. The 
skin should generally, in the interval of application, be protected by a 
dusting-powder ; and the clothing worn next the skin should be of an 
unirritating character. 

Erythromelalgia is a term given by Mitchell to a condition in 
which the fingers or toes are the seat of burning or aching pain fol- 
lowed by areas of redness. Other observers report cases occurring in 
connection with multiple sclerosis, tabes, myelitis, meningitis, traumatic 
neuroses, and other nervous disorders. Mitchell and Spiller 2 found a 
peripheral neuritis in one case. 

1 Phila. Med. and Surg. Keporter, 1881, p. 677. 

2 Amer. Jour. Med. Sci., 1899, cxvii., p. 1 (with review of the subject and full bibli- 
ography ) . 



808 SENSORY DERMATO-NEUROSES. 



ANAESTHESIA. 

(Gr. a, privative; alc&qoig, sensibility.) 

In cutaneous anaesthesia one or all of the elements of cutaneous 
sensation may partially or wholly be lost. 

Analgesia, or insensibility to pain, may exist while the tactile 
sense remains unimpaired, or the reverse may be true. Thermo- 
anesthesia may alone be manifested, and sometimes is limited to heat 
alone or to cold alone. A curious illustration of this occurred in the 
person of a leper, whose hands were in all parts sensitive to the prick 
of a lancet and to contact with heated substances ; yet who exposed 
them for hours without protection to an atmospheric temperature of 
ten degrees below zero without even slight discomfort. 

The tactile sense is involved more frequently than in hyperes- 
thesia, and usually is absent in all cases of anaesthesia. It, however, 
may be retained unimpaired with loss of one or all of the other elements 
of cutaneous sensation, as sometimes occurs in anaesthetic leprosy or 
syringomyelia. The failure to appreciate some one or more properties 
(such as form, size, weight, density, and smoothness or roughness) of 
foreign bodies may be psychical in origin. 

Illustrations of cutaneous anaesthesia are furnished in the anaesthetic 
patches of leprosy, which may or may not exhibit textural skin- 
changes ; centric and eccentric paralyses ; syphilitic, hysterical, and 
ataxic disorders ; partial or complete anaesthesia of artificial production ; 
the several toxic narcoses ; traumatism of nerves by pressure, wound, 
or contusion ; the local anaesthesia induced by cold, frigorific mixtures, 
and substances capable of benumbing the sensitiveness of the skin ; 
coma, of whatever origin ; and a number of idiopathic cutaneous dis- 
orders, including several of the atrophies, scleroderma, and morphoea. 

PARESTHESIA. 

In paraesthesia there is a perversion of sensibility, as a result of 
which a given stimulus produces a sensation different from that which 
it would produce in health. One or all of the elements of cutaneous 
sensation may be involved. Contact with a warm object may give a 
sensation of cold or of pain. Derangement of the tactile sense may 
give erroneous impressions of the size, weight, roughness or smooth- 
ness, firmness, or other qualities of an object. Many other perversions 
of sensation occur, all dependent upon central or local disorder of the 
nervous system. Sensations may be delayed for some seconds after 
contact, or may persist after the latter has ceased. 

There may be an error of location, as when the patient refers the 
point of contact to the wrong place or to the wrong side. The paraes- 
thesia may be largely or wholly subjective, and frequently gives rise to 
the sensation of heat or cold, formication, tickling, dripping or pouring 
of liquids of various temperatures, etc. 



PRURITUS. 809 

PRURITUS. 1 

(Lat. prurire, to itch.) 

Symptoms. — Pruritus is a common form of paresthesia which is to 
be distinguished not only from prurigo, a rare disease of the skin 
already described, but also from the symptomatic sensation of itching 
which is occasioned by a number of cutaneous disorders, such as 
eczema, scabies, and the dermatoses produced by pediculi. 

Hebra was first to recognize the independent character of the dis- 
ease here considered ; but it is to be regretted that he did not give to 
it a name distinct from that which is also applied to a symptom com- 
mon to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced 
originally by cutaneous lesions. It may be general or be partial. In 
either form it begius usually by a tickling, pricking, crawling, or itch- 
ing sensation in the skin, which solicits the sufferer to rub, press, scratch, 
or otherwise irritate the affected integument. It usually occurs by 
accesses in the day or the night, much more often the latter, occasion- 
ally both ; and these accesses most frequently occur under the immedi- 
ate stimulus of some internal or external cause. Thus, moral emotions, 
a draught of cool air, the warmth perceived when in bed, the pressure 
of clothing, and often the substances applied externally with a view to 
the relief of the pruritus, suffice to determine a crisis. However firmly 
the sufferer may determine to avoid injury to the person, in well-marked 
cases the impulse to scratch becomes well-nigh irresistible and in the 
highest degree tormenting. From the milder, the patient will thus fre- 
quently be teased to inflict the severer injuries upon the skin. Brushes, 
combs, coarse cloths, and even metal instruments are employed in severe 
cases for the purpose of assuaging temporarily the local distress. 

The objective cutaneous symptoms which may be presented are all 
secondary, and invariably result from self-inflicted injury. In some 
cases they do not appear, the statements of the patient being the sole 
basis for the recognition of the disease. This absence may be the con- 
sequence of unwonted self-control, or of the mildness of the malady, 
or of the transitory character of the lesions produced. Thus, the skin 
may be reddened during a nocturnal paroxysm under the manipulation 
of the sufferer, and the transitory hyperemia disappear in the daytime 
when the skin is submitted for inspection. Not rarely, however, the 
integument resents the treatment to which it is subjected, by displaying 
wheals, hypersemic blotches, reddened papules, excoriations, charac- 
teristic " scratch-lines," and the minute blood-crusts which indicate 
that the papillary layer of the derma has been reached and slightly 
torn. Dermatitis in varying degrees, and even eczema, may result, and 
still further add to the subjective distress. Skins that for years have 
been the seat of a persistent pruritus leading to traumatisms of the epi- 
dermis frequently show smaller or larger areas of deep pigmentation. 
The lesions may simulate those of persistent urticaria or of prurigo. 2 

1 For fuller discussion of the subject and bibliography, see Jacquet, La Pratique 
Dermatologique, iv., p. 341. 

2 Cf. Hartmann, Archiv, 1903, lxiv., p. 381 (bibliography). 



810 SENSORY DERMATO-NEUROSES. 

Cases are reported by Leloir and others in which a pruritus was fol- 
lowed by a dermatitis not due to traumatism, and persisting for con- 
siderable periods of time, or until relieved by treatment directed to the 
condition of the nervous system. These cases are called by the French 
Neurodermia, or Neurodermatitis, and are probably due to vaso- 
motor or other neurotic disorders. 

Senile Pruritus is a term often loosely applied to any form of the 
disease occurring in the aged, in whom it is very common. In the 
large majority of cases, however, careful search will disclose causes 
identical with those found earlier in life. Among the most common of 
these causes are : defective digestion, metabolism, „ assimilation, and 
elimination, with the resulting hepatic, nephritic, circulatory, arthritic, 
and neurotic disorders so frequently seen in those advanced in years. 
Senile pruritus proper is that form of the disease due to atrophic and 
degenerative changes in the skin and other tissues of the aged, and is 
practically remediless. 

Pruritus Hiemalis is considered at the close of this chapter. 

The localized forms of pruritus, albeit the abnormal sensation is in 
them limited to certain regions of the body, may occasion fully as much 
distress as those in Avhich a larger part of the integument is affected. 
They are of more frequent occurrence than the generalized forms. Pru- 
ritus of the anus, of the scrotum, of the vulva, of the vagina, of the 
scalp, of the nose, of the mouth, of the axilke, are all localized forms 
of the disease, two or more of w T hich may coexist or may develop in 
succession. 

Pruritus Narium is a frequent symptom of irritation of the Schnei- 
derian membrane. It is thus a common precursory or an attendant 
phenomenon of rose- or hay-asthma ; and in some individuals announces 
the systemic effect after ingestion of opium and its alkaloids. It occurs 
also in children as a result of pediculosis of the scalp. It may result, 
further, from the irritation awakened by intestinal parasites. 

Pruritus Genitalium is often an exceedingly severe and dis- 
tressing affection. As the parts in question are apt to be rubbed and 
scratched in efforts to secure relief of the itching sensation, there may 
be produced orgastic effects and pollutions, the moral results of which 
are degrading. The scrotum, the labia majora and minora, the penis, 
the clitoris, and the adjacent cutaneous and mucous surfaces may be the 
seat of the pruritus. Search should always be made in these cases for 
ascarides of the rectum or of the vagina, for saccharine and albuminuric 
urine, and uterine or ovarian affections. A perverted sexual hygiene 
may lie at the root of these disorders. In severe cases the violence 
with which the parts are attacked suggests frenzy on the part of the 
patient, who at times is never content until the scrotum or other parts 
are bathed in blood. The thickening, erosions, and excoriations of the 
regions attacked are conspicuous features of the disease. 

Pruritus Ani. — This is a disorder of adults of both sexes, and it 
may coexist with pruritus of the genital region. There is usually noc- 
turnal exacerbation. The anus may become infundibuliform from in- 
duration ; its mucous surface excoriated ; its cutaneous borders seamed, 
puckered, eroded, and fissured. It is often complicated with, because 



PRURITUS. 811 

the origin of, an eczema the lesions of which reach upward over the 
coccyx or forward to the genital region over the perineum. Hemor- 
rhoids, fistula in ano, ascarides, chronic prostatitis, rectal impaction 
and fissures, proctitis, unnatural practices, gout, alcoholism, albumin- 
uria, or diabetes may each be responsible for its occurrence. 

Pruritus Palm^: et Plants is a rare form of this disorder, in 
which the itching is limited to the palms and soles. It may complicate 
gout, malaria, hyperidrosis, and asthma. 

Pruritus Linguae is reported in a few instances. It usually is 
due to a central neurosis, to glycosuria, or other systemic disease. 

Stelwagon 1 describes cases of bath-pruritus in which an attack of 
itching or burning follows a bath. The pruritus lasts from a few min- 
utes to an hour or more, and is limited usually to the legs and thighs, 
but may affect other parts of the body. We have seen several such 
cases. A mild degree of pruritus following the bath is not uncommon 
in certain individuals with sensitive skins. 

In all severe forms of pruritus cutaneus the general health per- 
ceptibly fails. Whether the prolonged insomnia arises from nocturnal 
exacerbations to which there are but few exceptions ; or from the per- 
version of nutrition incident to the continuous teasing of the nervous 
system ; or yet from the hypochondriacal state into which some patients 
are plunged by their sufferings, such an issue is often to be expected. 
It Js, in fact, a complication that may merit, as much as the disease 
itself, the attention of the physician. 

Etiology. — The causes of pruritus are numerous, and the necessity 
for the discovery of the particular cause in each patient often makes the 
largest demands upon the practitioner. The disease may occur at all 
periods of life and in both sexes, but its aggravated forms are peculiar 
to middle life and advanced years. It is always secondary to some 
disturbance of the nervous system. It is frequently the symptom of one 
of several internal disorders, such as malarial affections, tuberculosis, 
carcinoma of the viscera, disorders of the liver or kidneys (especially 
jaundice, Bright' s disease, and diabetes), and disturbances of the ali- 
mentary canal, including those due to intestinal worms, hemorrhoids, 
and dietetic or medicinal ingesta. It is common in the gouty, the 
rheumatic, and the neurotic, and undoubtedly is due often to auto- 
intoxication. It is often reflex in character, and may be associated with 
almost every one of the functional, and not a few of the organic, dis- 
orders of the uterus and ovaries. The same may be said of its depend- 
ence upon the genito-urinary diseases of the male sex, including stone 
in the bladder, stricture of the urethra, disorders of the testes and epi- 
didymis, and perverted sexual hygiene. Through the reflex sympathy 
of one part of the skin with other regions it is not at all unusual for 
one point of pruritus to be the exciting cause of new foci of the dis- 
order, even at some distance from the original seat of itching. A 
predisposing cause may often be found in hyperesthesia, either inherited 
or acquired (sometimes as a result of long-continued inflammatory der- 
1 Phila, Med. Jour., 1898, ii., p. 863. 



812 SENSORY DERMATO-NEUROSES. 

matoses, such as eczema), as a consequence of which insignificant exter- 
nal irritants cause pruritus. Bronson 1 thinks a diminished tactile sense, 
which implies an imperfect conduction of sensory impressions, is often 
a predisposing cause. 

Lastly, moral emotions of a depressing character play an important 
part in the etiology of pruritus. Mental distress occasioned by bereave- 
ment, separation from relatives, misfortune of all sorts, and anxieties 
as to the future, often find physical expression in the disease. 

Pathology. — The disease is essentially a functional disorder of the 
nerves of sensation supplied to the skin, and of itself is incapable of 
producing objective symptoms. This fact can, in some cases, be clin- 
ically demonstrated, as the seat of the pruritus, even though exhibit- 
ing artificially produced lesions, will, when protected from external 
injury, speedily regain its normal appearance, the pruritus no less con- 
tinuing. It is probable, though not certain, that the nerves also in 
this disease undergo no structural change, but merely convey to the 
periphery a perverted sensation that is often reflected from some cen- 
tric point of disturbance. 

Diagnosis. — The recognition of general pruritus is usually not diffi- 
cult, though the secondary results of the disease are apt to be less 
characteristic than its early phenomena. The complaint of the patient, 
the absence of cutaneous disease sufficient to explain the symptoms, 
and especially the discovery of an efficient cause in some visceral or 
systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible only 
when the clothing of the patient is entirely removed. It then becomes 
evident to the eye that the affected regions are, in the order of fre- 
quency, those most accessible to the hands. The posterior are much 
less involved than the anterior body-surfaces. The small of the back 
and interscapular regions are usually untouched. The tibial regions 
of the legs and the forearms suffer more than the calves and the upper 
arms. The lower belly and inner faces of the thighs are punished 
more severely than the breast and outer faces of the thighs and the 
hips. The clavicular regions are more excoriated than the back of the 
neck. There is no more diagnostic sign of pruritus than this, and it 
is one too often ignored by the practitioner, who prescribes under these 
circumstances for a " disease of the blood." 

It must be admitted, however, that when the disease is localized 
and complicated, as it frequently is, by an eczema or a dermatitis, 
doubt may arise. Attention should then be paid to the history of the 
disorder, which may reveal the fact that the pruritus preceded for some 
time the cutaneous symptoms, and may disclose even more. Intelli- 
gent patients will often assure the physician of the real nature of the 
malady, by voluntarily remarking that the skin-symptoms disappear 
upon the region that is not scratched, though the pruritus continues. 
In all cases the influence of externally operating agencies should care- 
fully be eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its severe 

1 " Etiology of Itching," Med. Kecord, 1891, xl., p. 497 (a careful review of the subject). 



PRURITUS. 813 

itching, beginning in early infancy and commonly persisting through 
life, can scarcely be confounded with pruritus cutaneus. 

Treatment. — The degree of success to be obtained in the treatment 
of pruritus cutaneus is largely proportioned to the skill with which the 
cause of the disease is recognized and remedied. Taking into consid- 
eration the number of systemic and visceral disorders which may in 
different cases be responsible for the skin-symptoms, it is clear that an 
exhaustive study of the mental and physical history of each patient 
will be essential at the outset of treatment. The cause once recognized, 
the treatment should be directed to the special disorder discovered ; and 
this largely requires the skill of the general practitioner. The gastro- 
intestinal tract, the kidneys, the liver, the bladder, the uterus, the 
prostate gland, the rectum, and indeed any one of the viscera, may 
require therapeutic management. All internal causes of cutaneous 
irritation should as far as possible be removed, and to this end atten- 
tion should particularly be directed to any medication to which the 
patient may have been subjected, and which may have aggravated the 
complaint, and also to the diet, which should be regulated in accord- 
ance with the principles given under Urticaria (page 194) and Eczema 
(page 346). 

In atonic conditions strychnine, iron, and other tonics are indicated. 
The nutrition of the nerves and of the skin can often be improved by 
the judicious use of cod-liver oil and other fats. 

The attempt to relieve pruritus by the internal use of sedatives is 
not to be commended except in extreme cases. The narcotics, while 
they may give temporary relief, tend to relax the skin and in the end 
to aggravate the disorder. This is especially true of the preparations of 
opium. The bromides, antipyrin, phenacetin, sulfonal, or even chloral 
may be given for brief periods in extreme cases, but always with the 
understanding that any one of these remedies, after temporary relief, 
may aggravate the condition for which it was given. Furthermore, 
there are strong reasons for refusing to employ in pruritic disorders 
preparations containing opium, cocaine, cannabis indica, conium, and 
other drugs intended to relieve the subjective sensations by internal 
medication. Many well-nigh incurable cases of the " cocaine-habit " 
have been begotten by treatment of this sort when the patient, often a 
nervous woman with an intolerable pruritus vulvae, is in a condition 
peculiarly susceptible to the action of remedies of this class. The 
latter should always be regarded as the last resort of the practitioner, 
and a confession of weakness in not discovering the special cause 
effective in the case with which he is for the time confronted. 

Cathartics and laxatives and an abundant supply of pure water 
internally employed as directed for relief of acute eczema (pp. 381, 382), 
as well as diaphoretics and diuretics, are often of value in eliminating 
toxins to which pruritus may be due ; in depleting the cutaneous ves- 
sels ; and possibly in a reflex way by diverting irritation to other 
regions. Jaborandi and pilocarpine have thus been employed to ad- 
vantage. In children full doses of quinine sometimes relieve pruritus, 
while in adults large doses of calcium chloride occasionally will accom- 
plish the same result. Cannabis Indica and gelsemium at times are 
effective, but should be prescribed with great caution, 



814 SENSOBY DERMATO-NEVROSES. 

The indications for local treatment are to protect the skin from all 
sources of irritation and to relieve the itching. Hyperesthesia of the 
skin is common in pruritus, either as a predisposing cause or as a result 
of long-continued pruritus. In consequence very slight external irri- 
tation may suffice greatly to aggravate the itching, and every precaution 
should be taken to protect the skin from exposure of all kinds. First 
in importance is the clothing. The garments worn next the skin should 
be of cotton, lisle-thread, linen, or silk, never of wool, and the meshes 
should be filled with an impalpable powder to reduce to a minimum 
the friction of the garments on the skin. All other clothing should 
be as light as possible and yet be warm enough for protection. If the 
patient live in a climate where sudden changes in temperature are com- 
mon, the clothing should be regulated accordingly. The object is to 
keep the skin at an even temperature and to protect it from sudden 
changes. In cases in which the pruritus is due largely to the hyper- 
esthesia the itching may be entirely relieved by dusting the surface 
with a simple powder and completely covering it with a layer of cotton- 
wool or other protective dressing. 

Hot baths, unless specially indicated, and the too free use of soap 
may render the skin unduly sensitive. The bran, oatmeal, alkaline, 
and other demulcent baths recommended in the chapter on General 
Therapeutics are those most generally useful. After the bath the 
surface should be patted (not rubbed) dry and covered with a dusting- 
powder or other selected application. When the skin is free from ex- 
coriations and other lesions the cold douche, alternate hot and cold 
douching or sponging, or even the cold salt-water sponge may be used 
to improve the tone and vigor of the skin. For localized pruritus hot 
baths of four or five minutes' duration, followed by drying and the 
immediate application of a protective dressing, are often grateful and 
beneficial. The water should be as hot as can be tolerated, and to it 
may be added borax or sodium bicarbonate. 

Scratching is a common source of irritation and one that is difficult 
to set aside. Until this is accomplished, however, relief cannot be ob- 
tained, as whenever the skin is scratched or rubbed there is produced 
a local hyperemia, or even a dermatitis, which adds to the cutaneous 
irritation, not only at the site of the rubbing, but also by reflex action 
in other regions of the body. It is not sufficient to tell the patient not 
to scratch ; the surface must be protected by proper dressings, and the 
itching relieved by the use of antipruritics. Br'onson suggests that 
patients be allowed to obtain relief at times by firmly pressing upon 
the surface or by gently drawing over it an oiled or a wet cloth. 

The substances which have been employed topically for the relief of 
pruritus cutaneus are almost without number, a fact warranting the 
conclusion, corroborated with every wide clinical experience, that each 
occasionally fails to afford the desired relief. That preparation, more- 
over, which is at one time of the highest value, at another period in 
the history of the same case will disappoint. Attempts to secure relief 
by such topical applications should, however, always be made, and will 
often be followed by gratifying results. 

The sedative and antipruritic lotions, liniments, and dusting-powders 



PRURITUS. 815 

described on pages 342-345, together with their methods of prepara- 
tion and application, are valuable and sufficient in most cases. They 
may be further modified by the addition of substances recommended in 
the following paragraphs. The dusting-powders are of special value 
in furnishing mechanical protection. When a decided antipruritic 
effect is desired the Anderson, or a similar, powder may be used. In 
some localized forms of pruritus more complete protection with oint- 
ments, pastes, or even the glycogelatins, may be secured. 

Of all antipruritics, carbolic acid easily takes first place. In most 
of the lotions recommended above it is used in strength of 1 to 5 per 
cent. In oils or liniments it may be used much stronger. Bronson 
uses it even to 25 per cent., stating that it is much more slowly ab- 
sorbed than in aqueous solutions, and therefore less likely to produce 
systemic effects. A favorite formula with him is the following : 



R 



Acid, carbolic, 


3j-ij ; 


4-8 


Liq. potass., 


33; 


4 


01. lini, 


3j; 


30 



M. 



It is to be shaken before using, and may be scented with bergamot. 
These stronger preparations of carbolic acid, even in the oils, should 
be used over only small areas, for fear of toxic effects. The possibility 
of producing gangrene by the long-continued application of even weak 
solutions of carbolic acid should never be forgotten. (See page 230.) 

Other remedies that may be used in lotion, oil, liniment, ointment, 
or paste, in strengths varying from 1 to 5 per cent, or more are : 
salicylic acid, hydrocyanic acid, menthol, camphor, thymol, salol, creo- 
sote, chloral, and chloroform. Two or more of these remedies may be 
combined in the same lotion. Morphine, atropine, and cocaine may be 
added to lotions with occasional advantage. 

Ointments and pastes are irritating to many pruritic skins, but at 
times are more acceptable than the lotions and oils. In abnormally 
dry skins and in some cases of bath-pruritus a simple oiling of the 
skin often gives prompt relief. 

Chloral-camphor, a pungent, syrupy liquid obtained by triturating 
an equal amount of the two substances in fine powder, is an anti- 
pruritic remedy of value in certain cases if applied in a salve contain- 
ing 1 drachm (4.) to the ounce (30.) of salve, and is comparable in its 
action to phenol-camphor, described in the chapter on General Thera- 
peutics. Among other remedies occasionally of service are ichthyol, 
resorcin, and mercuric chloride. Bronson speaks highly of hydrogen 
peroxide. The preparations of tar are not well tolerated as a rule, but 
in some instances are exceedingly valuable. The liquid preparations 
(page 399) are to be preferred. In atonic cases, with diminution of 
the tactile sense, the use of electricity over the spine has been followed 
by good results. 

In Senile Pruritus the progressive atrophy and degeneration of 
tissues may be checked or retarded by management proper to each 
case. Locally, electricity or hot and cold douches may aid in stimu- 
lating the skin to renewed vigor. Keeping the skin soft with daily 
inunctions of oil or a thin ointment is an effective measure in many cases. 



816 SENSORY DERMATO-NEUROSES. 

Treatment of the regional forms of pruritus is that above de- 
scribed, with such modifications in the dressings as may be necessitated 
by the special location. 

In anogenital pruritus the hot bath described above at night is 
especially to be recommended. Exception should be made here to the 
rule with regard to the exclusion of tars generally from the treatment 
of pruritus, as in the distressing itching of the scrotum and the anus 
they are often essential. The tincture of tar, oil of cade, and oil of 
white birch will here often be needed. Fissures and areas of infiltra- 
tion may be painted with compound tincture of benzoin or solutions of 
silver nitrate containing gr. x to 3J (0.66-4.) to the ounce. The scrotum 
when attacked usually requires the use of a suspender, or suspensory bag, 
lined with soft lint or with borated cotton, which may be covered with 
a dusting-powder, wetted with a lotion, or smeared with an unguent. 

We have succeeded in relieving a number of severe cases of ano- 
genital pruritus with the a>rays, and have found this treatment of 
value in localized pruritus of other parts of the body. Other observers 
report similar results. High frequency currents are recommended by 
some writers. We have found the method of less value than the a;-rays. 

For pruritus of the vulva Wiltshire 1 recommends decoctions of 
almond-meal, marshmallow, slippery-elm, and rice ; and in case of 
failure of the latter, an infusion of tobacco 2 ounces (60.) to the pint 
(480.). Vaginal injections of hot water, and tampons or cocoa-butter 
suppositories medicated with opium, belladonna, or carbolic acid, are also 
available. Mercuric chloride lotions [gr. J-j to sj (0.016-0.06 to 30.)] 
are recommended by many writers. 

Iodoform, oleate and muriate of cocaine, the latter in from 2 to 4 
per cent, solutions ; 1 ounce (30.) of the fluid extract of coca, to 2 or 
4 (64.-128.) of water ; and linseed oil (especially for pruritus ani), are 
also recommended. 

Jullien recommends in pruritus of the vulva : 



M. 



Cheron, in pruritus of the vulva attending the menopause, has 
successfully used : 

R Veratriae, gr. iij ; 120 

Axung., gj; 30| M. 

He also administers in pill-form y^- grain of veratria rubbed up 
with licorice. 

Squibb's formula is : 

R Acid, tannic, 9j ; 1 33 

Glycerin., j - ^ - - lg 

Spts. vin. rectif., j ° ' 

Aq. dest.. ad f §iv ; ad 120 M. 

Sig. Apply morning and evening on a rag. 



R Zinc, oxid., 


3vj; 


24 


Acid, salicylic!, 


gr. xv ; 


1 


Glycerin., 


3vj; 


24 


Sig. Apply as required. 







Brit. Med. Jour., 1881, i., p. 327, 



PRURITUS. 817 

Lastly, it should not be forgotten that many cases of intractable 
pruritus are best managed when the attention of the patient is diverted 
from the malady by the distraction incident to travel, aided by change 
of scene and climate. 

Prognosis. — Pruritus senilis is usually an intractable disorder, and 
when dependent upon senile alteration of the cutaneous tissues is in- 
curable. For all other forms of the disease a prognosis should be 
formulated with reserve. Under the influence of systematic and ap- 
propriate treatment the happiest results are often obtained. Other 
cases, especially those associated with hypochondriasis, may bid defi- 
ance to all medicinal measures. Relapse of the local forms of the 
malady, especially of that of the anogenital region, is common. In 
many of these patients the treatment serves merely to palliate the 
disorder, which recurs with every renewal of the cause. 

Pruritus Hiemalis (Prurigo Hyemalis, "Frost Itch," 
Winter Prurigo). — Under the first title Duhring 1 described a harsh 
and pruritic condition of the skin, essentially unattended by structural 
alteration, invading all surfaces of the body, but chiefly the inner 
faces of the thighs, the calves of the legs, and the neighborhood of the 
joints of the lower extremities, usually occurring in the autumn and 
continuing until the following spring. It possesses many features in 
common with the forms of pruritus already described, including varia- 
bility in the subjective sensations awakened, nocturnal exacerbation, 
and the absence of primary eruption. The secondary results are also 
similar, being sequels of self-inflicted injury in the form of roughness, 
perifollicular redness and papulation, torn and fractured hairs, excori- 
ations, blood-crusts, and, in severe cases, an induced dermatitis. It, 
however, abates in severity with a rise of atmospheric temperature, 
though there is occasionally noted persistence of the distress after such 
weather-changes. The affection, moreover, is one which occurs in 
persons otherwise enjoying perfect health, in those of every social 
grade, irrespective of the ^character of the clothing worn and of the 
habitual use or the neglect of the bath. It is, without question, a dis- 
ease of northern climates, more particularly of those where the varia- 
tions of temperature between the extremes of the summer and of the 
winter range between — 30° F. and 100°. The description by Duh- 
ring presents a picture (with an accuracy verified by clinical observa- 
tion) which justifies the recognition of the disease as a form of cutaneous 
pruritus. Its treatment is that detailed above, the author named lay- 
ing stress upon emollient unguents, glycerin in the form of lotion or 
ointment, and alkaline baths. The dusting-powders, when employed 
after the tepid bath, have proved more serviceable than any fat-con- 
taining substance. 

Prairie Itch. — This is a popular term applied largely in the 
Western, Northwestern, and Southern States of America to a cutaneous 

1 Phila. Med. Times, January 10, 1874. See also a later but independent observa- 
tion by Hutchinson : Lectures on Clinical Surgery, 1878, vol. i., pt. 1, p. 100; and Brit, 
Med. Jour., 1875, ii., p. 773. 
52 



818 SENSOBY DERMATO-NEUBOSES. 

affection productive of itching sensations. It is supposed to be the dis- 
order popularly described also as the " Texas Mange/' " Ohio 
Scratches/' " Swamp Itch," " Lumberman's Itch/' etc. A para- 
sitic origin has been claimed for it by several observers who also 
insist upon its contagious character and its curability by parasiticides. 

Personal experience has led to the conviction that these terms are 
loosely applied to a group of cutaneous symptoms of diverse origin. 
The most frequent by far is a pruritus, of the kind described above as 
pruritus hiemalis, occurring in the autumn, winter, or spring of the 
year, and aggravated by the coarse and cheaply dyed woollen under- 
garments of the poor and hard-working inhabitants of lumber-camps, 
mining-districts, etc. With these causes in full operation, there is often 
aggravation after swallowing drugs for relief of the pruritus, based upon 
the idea of " purifying the blood." 

With these pruritic cases occur those of undoubted scabies, for the 
study of which the reader is referred to the chapter devoted to that 
subject. The proportion between the purely pruritic and parasitic 
cases of this class cannot definitely be determined. It probably varies 
in different places and seasons, the proportion of cases of scabies 
increasing in the lumber-camps when they are reinforced by newly 
arrived immigrants infested with acari. It decreases to probably not 
more than from 1 to 2 per cent, of all skin-diseases in the interior vil- 
lages and towns of the West and Northwest where there has been no 
immigration for some length of time, and where, after the first onset of 
sharply cold weather in the autumn, a large part of the inhabitants 
suffer from pruritic sensations in various degrees. 

A review of the somewhat scanty literature of this subject l suggests 
the conclusion that the disorder popularly designated as " prairie itch," 
etc., is far more rare in Europe than in America. It is possible that 
the situation of those parts of the United States Avhere this group of 
skin-affections seems to prevail (at a great distance from proximity to 
the seashore, and still further separated from the Gulf-stream) may play 
an important part in the extraordinary sensitiveness of the skin to 
climatic changes. Certain it is that a great number of these affections 
are entirely relieved by removal to a suitable climate, more particularly 
to one of the Eastern, Southern, or extreme Western States. 

Treatment. — The therapy of this affection is that of pruritus, 
already described, save where a parasite is recognized as the efficient 
cause, as in cases of scabies. 

The Prognosis is favorable, though the disease is at times intracta- 
ble, persisting or recurring with repeated thermometric variations until 
the warm season is at hand. 

1 See two papers by one of us, entitled " On the Affections of the Skin Induced by 
Temperature-variations in Cold Weather," Chicago Med. Jour, and Exam., 1885, lii., 
p. 187, and 1886, liii., p. 116. Obersteiner: Wien. med. Wchnschrft., 1884, No. 16. 
Brodie : Peninsular Jour. Med., 1853-54, vol. i., p. 506. Jones : Kansas City Med. 
Index, 1 886, with views of several Western physicians. Clark : Med. Age, 1886. Payne : 
Brit. Med. Jour., 1887, i., p. 985. Corlett, Jour. Cutan. Dis., 1894, xii., p. 457, and Jour. 
Amer. Med. Assoc, 1902, xxxix., p. 1583. 



MYXCEDEMA. 819 

MYXOEDEMA. 

(Gr. fivga, humor ; oISecj, to swell. ) 

(Cretinoid CEdema, Cachexia Strumipriva, Cachexia Thy- 
roidea. Fr., Cachexie pachydermique.) 

This disorder was first described by Sir William Gull/ in 1873; 
and it has since been studied, both abroad and in this country, by many 
observers. 

A complete description of the disease and a resume of literature are 
found in the report of the Clinical Society of London for 1888, and in 
Murray's elaborate contribution to the same subject, in the Twentieth 
Century Practice of Medicine, vol. iv., 1895. The report embodies the 
results of the researches of a committee — including Ord, Horsley, and 
others — specially appointed by the Society to investigate the subject. 

Symptoms. — The disease occurs in both acute and chronic manifes- 
tations, usually after the fortieth year, and in women more often than 
in men. It may, however, first be noticed in childhood. 

At the outset there is observed a gradually occurring persistent and 
remediless anaemia, succeeded in turn by mental hebetude, sluggish- 
ness of body-movements, and a characteristic change in the integument. 
The skin becomes dry, rough, yellowish, waxy, translucent, and firm, and 
refuses to pit on moderate pressure. The surface involved is commonly 
the seat of a fine furfuraceous desquamation, the mucous membranes 
often participating in the morbid process. In the cheeks there is 
usually perceptible a brawny redness ; defined at times as a sharply 
circumscribed, pinkish flush, due to distention of the minute capillaries, 
extending quite to the lower eyelids, which may, as in Ball's cases, be 
wrinkled, boggy, and swollen. The eyes, for this reason, seem smaller 
than natural and more widely separated. In consequence of the swelling 
and immobility of the features the facies is characteristic : the broad, 
thick nose ; swollen, pendulous, or even everted lips ; expressionless 
eyes ; and leathery cheeks, producing upon the observer the impression 
of a mask. The skin of the other regions of the body participates in 
these changes, the backs of the hands, for example, becoming wrinkled 
or distended, the palms dry and fissured, the feet participating in the 
same morbid process, the hair falling in nearly 90 per cent, of cases 
even to the production of extreme baldness, the nails becoming discol- 
ored, grooved, and cracked, and the teeth often carious, fragile, or 
wholly lost. The mucous membrane of the mouth (gums, palate, 
pharynx) becomes tumid and fungous. 

In the triangles at the side of the neck, and also at its back, are 
" bolsters " of fat. The hair of the head becomes harsh and scanty ; 
alopecia may be complete. Pigment-alterations readily occur; moles 
increase in size ; and the general tint of the skin may vary from that 

1 Trans. Clin. Soc, London, 1874, vii., p. 170. See, also, Hun, Amer. Jour. Med. 
Sci., 1888, p. 196 (notes on 150 cases in literature), and later reports by Adami, Trans. 
Fourth Cong. Amer. Phys. and Surg., 1897 (review of subject and bibliography), and 
Murray, Lancet, 1899, i., pp. 667 and 747. 



820 THYROID CACHEXIA. 

of dry parchment to the hue of Addison's disease. The gait is waddling 
and uncertain. The thyroid gland atrophies. Anaesthesia is of common 
occurrence. The tongue, uvula, and fauces are often so thickened and 
immobile as to make speech slow and indistinct. The temperature is 
usually subnormal, the mental faculties seriously impaired, the sight 
and hearing altered, digestion vitiated, and the muscular strength 
greatly reduced. 

The course of the disease is chronic, lasting for years, and termin- 
ating usually in a state of marasmus with fatal issue. 

Etiology. — The cause of myxoedema is imperfectly understood, 
though its association with abolition of the thyroid gland (after patho- 
logical change or ablation) is generally admitted. Stokes reports ten 
cases of acute myxoedema following thyroidectomy. In these cases, 
beside the rapid occurrence of the symptoms enumerated above, there 
were convulsive seizures of an epileptiform character. Of four hundred 
and eight complete thyroidectomies analyzed in the Clinical Society's 
report, in sixty-nine myxoedema developed. The result did not occur 
when a part of the gland was left. The influence of heredity is distinctly 
shown in cases reported by Ball, Ord, Saville, and Taylor. The disease 
affects women more often than men, in the proportion of seven to one. 
Children are attacked, but the malady is more common in individuals 
between thirty-five and fifty years of age. 

It is undetermined what relations, etiological or other, subsist between 
the members of an interesting group of maladies, all characterized by 
cutaneous changes or dystrophy of the appendages of the skin, and total 
or partial abolition of the functions of the thyroid gland. In this group 
are to be named not merely myxoedema, but also myxoedematous cretin- 
ism, acromegaly, and Graves's disease. These maladies are denomi- 
nated by some authors the " thyroid cachexias." 

Pathology. — In nearly all cases examined the thyroid gland is 
found to be markedly reduced in size and its glandular structure 
seriously impaired by substitution of fibrous connective tissue for the 
epithelial cells lining its secreting acini. At first there is a small 
round-cell proliferation, which gives place to changes resulting even- 
tually in a firm thickening of both the gland and its capsule. The 
lumen of the arteries becomes obstructed ; and, in cases, new-formed 
lymphatic tissue is found surrounding the atrophied lobules. 

Examination of affected regions of the skin discloses slight epider- 
mal atrophy, replacement of connective-tissue trabeeulse with fine 
nucleated fibrillse, a small-cell infiltration in the upper part of the 
corium, and an endarteritis obliterans similar to that recognized in the 
thyroid gland. The epithelium of the coil- and sebaceous glands is the 
seat of swelling and proliferation, which eventually produces occlusion 
of the lumen of these emunctories and explains largely the cutaneous 
symptoms of the malady. The hair-follicles and the nerves (fibrosis 
of hair-pouch, perineuritis) may or may not be invaded by a similar 
process. 

Diagnosis. — Cases of myxoedema are readily distinguished from 
those of elephantiasis by the generalization of the symptoms, the nervous 
state of the patient, the fat-deposits, and the condition of the thyroid 



MYXEDEMA. 821 

gland. Acromegaly involves the bones ; in lepra there are commonly 
anaesthetic symptoms or characteristic tubercles. 

The Treatment of myxoedema has hitherto aimed at amelioration of 
the symptoms by the employment of roborant and tonic measures ; alka- 
line and sulphur baths ; electricity and massage. The later method of 
treatment, however, is by thyroid-grafting, by administration of thyroids, 
and by hypodermatic injection of from 5 to 15 minims of liquid extract. 1 
Whether there be employed the gland itself of the sheep, the liquid 
extract, or the powder skilfully prepared by evaporation, or Vermeh- 
ren's extract precipitated by alcohol, the results are satisfactory in so 
large a proportion of cases that the prognosis of this group of disorders 
presents no longer an element of gravity. The headache, faintness, 
loss of weight, neuralgias, and even albuminuria, with other symptoms 
immediately following the employment of the thyroids named above, 
do not seem to have an adverse influence upon the remoter benefits 
received from the treatment. 

1 Cf. " Feeding Thyroids in Myxoedema," by J. J. Putnam ; Amer. Jour. Med. Sci., 
August, 1893. 



CLASS VIII. 
PARASITIC AFFECTIONS 



The disorders due to invasion of the skin by parasites possess many 
features in common with those already described. In them, as in others, 
are observed the hypersemic and exudative processes which result in 
surface-lesions of similar type and career. They differ, however, from 
other affections of the integument in that they are all induced by para- 
sites of either vegetable or animal origin ; and are, as a consequence, 
commonly characterized by certain special features. They involve the 
skin and its appendages, their symptoms being at times displayed 
chiefly in the integument proper, and at other times in one or more of 
the cutaneous appendages, according to the mode of propagation and 
attack, peculiar in each case to the parasite present. They are all in 
different degrees contagious ; and, being induced by local and tangible 
causes, are usually relieved by external treatment. Their importance 
in cutaneous medicine rests not only upon the facts named above, but 
also upon the too general misconception regarding their nature, since 
there are many patients treated by internal remedies ingested vainly 
for long periods of time, who suffer from parasitic disorders often 
remediable by very simple local measures. 

It should not be forgotten, however, that, distinct though these mal- 
adies be in an etiological sense, they are yet often practically com- 
mingled with others. Thus, an eczematous scalp in a child may by 
accident become the habitat of lice ; and the eczema induced originally 
by the acarus scabiei may persist long after destruction of the parasite. 

The term tinea, derived from a Latin word meaning " a moth or 
worm," has by common consent been adopted as a generic designation 
of the cutaneous disorders induced by the presence of vegetable organisms. 

DISORDERS DUE TO VEGETABLE PARASITES. 
TINEA FAVOSA. 1 

(Lat. favus, a honeycomb. ) 

(Honeycomb Ringworm, Porrigo Favosa, Favus. Fr., Teigne 
Faveuse; Ger., Erbgrixd.) 

Symptoms. — Favus affects chiefly the scalp, but it also occurs upon 
the glabrous portions of the skin and upon the nails. In the former 
situation it is usually first recognized by the development of minute, 
subepidermic, yellowish or reddish puncta, visible through the trans- 
lucent stratum corneum at the site of implantation of the hairs. A 
1 For bibliography, see Bodin, La Pratique Dermatologique, ii., p. 617. 

823 



824 ' PARASITIC AFFECTIONS. 

circle of delicate vesicles may surround these spots. Puncture with 
a needle usually gives exit to puriform matter. In the course of a 
fortnight or more these lesions cover themselves with pin-head to 
pea-sized and somewhat larger, friable, circular, and elevated crusts, 
having the yellowish tinge of the lemon or of sulphur, and a concavo- 
convex shape, with the free concave face of the disk exposed. At 
the centre of the umbilication thus presented to the eye one or several 
hairs usually make exit to the surface. The inferior surface of this 
disk, or scutulum, rests upon the scalp, which is either moist and 
deprived over a circumscribed area of its epidermis, or is smooth, dry, 
reddened, and tender. When the crust is removed by traction upon 
the hairs or otherwise a minute cup-shaped depression is left at the 
point where the lowest level of the favus crust was in intimate con- 
nection with the epidermis. 

The subsequent features of the crusts, the hairs, and the scalp are 
subject to variation. The crusts may acquire a brownish or a greenish 
tinge by admixture with dirt or with dried pus ; may coalesce (favus 
squamosus); or may, by gradual desiccation, exchange the yellowish 
hue for the dirty-whitish shade of old mortar, a substance which they 
then resemble in dryness and friability. The hairs invaded both in 
the sheath and shaft may lose their lustre ; become fragile ; appear as 
fractured relics of longer filaments ; readily be extracted from their 
follicles ; and finally be shed, leaving hair-sacs destined to atrophy and 
incapable of reproducing a pilary growth. The scalp may first be the 
seat of an extensive hypersemia or exudation going on to the forma- 
tion of pus, w T hen the fungus is a source of acute irritation in conse- 
quence of its active development. Later, when its destructive work 
may be said to have been accomplished, the scalp-surface is bald, irreg- 
ularly atrophied, or disfigured with cicatrices, which at first are of a 
deep-red color, but which gradually fade, while here and there remain 
tufts of hair that have survived the attack. 

The lesions may be discrete or be confluent, and may vary in either 
case. Occasionally but a few small and ill-developed crusts form upon 
the surface. The entire scalp is not often covered with a confluent 
favus-crilst. The disease is usually chronic in its course. Untreated, 
it may undergo spontaneous involution after total destruction of all 
hairs and production of general follicular atrophy, but this is rare. 
It may last for fifteen or twenty years, and even longer. It is often 
accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching, and, 
as a result, it is not rare to find the favus-crusts torn and broken by 
the comb or the nails. 

The yellowish disks of the disease occur also in typical development, 
though more rarely, upon the surface of the face (including the bearded 
cheeks, lips, and chin), and upon the trunks and extremities. Fox, of 
New York, has photographed a patient's knee which was covered on its 
extensor aspect with favus-crusts. 

When the nails are invaded, light or deep-yellowish, circumscribed 
spots become visible through the nail structure, and by extension of 
these, in consequence of the growth of the parasite, the nail-tissue 



TINEA FAVOSA. 825 

may be thickened, irregularly split, laminated, separated from its 
matrix, or atrophied. The complication is rare, and is supposed to be 
due to transfer of the parasite from the scalp to the hands in the act of 
scratching. When it exists the epidermis fringing the nail is usually 
also involved. 

Upon the so-called " non-hairy " portions of the body favus occurs 
in the same forms as elsewhere, the localities in the order of frequency 
being those most exposed to the hands charged with the parasite, or to 
other sources of the disease, viz., the hands (chiefly the backs and nails), 
the upper and lower extremities, and the shoulders. It is a striking 
fact that favus may exist for years on the scalp without spreading. At 
a single clinic we have exhibited five patients affected with favus, all 
scalp-cases, the eldest, a male, twenty-five years of age, who had suffered 
from the disease for twenty years without occurrence of the lesions 
elsewhere. 

In favus of the body-surface, outside the scalp, there is often a re- 
semblance to ringworm in the production of circular patches with an 
active border made up of vesicles or of papules, which may have a 
favus scutulum as a centre ; or several of these cups may irregularly 
be spread over circles of scaling patches. In these cases there is often 
an acuity of symptoms not observed in scalp-cases and coincident 
gastro-intestinal signs of irritation, vomiting, etc., which Kundrat be- 
lieves may originate in favus of the mucous surfaces of the oesophagus 
and gastro-intestinal tract. 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice ; also to that of the urine of cats. It should not be 
confounded with the peculiarly disgusting odor of neglected scalps 
affected with lice or covered with pustules and filth. The disease not 
infrequently coexists with other cutaneous, parasitic, and non-parasitic 
diseases, as, for example, seborrhcea, eczema, and tinea tonsurans. 

Favus of the Nail (Favic Onychomycosis). — Rarely one or 
several of the nails may be the seat of the fungus, and either the entire 
body of the nail or but a part of it. The lesions are maize-yellow 
points or macules where the substance of the organs is eroded, fissured, 
or split into striations — changes quite like those induced by other causes. 
The connections of the nail with the underlying nail-bed and nail-folds 
are loosened, wholly or in part, while the matrix still holds the nail 
firmly in position. 

Etiology. — Favus is always produced by the presence and develop- 
ment of the vegetable organism which is named after its discoverer, the 
achorion Schoenleinii (Fig. 89). The disease is contagious simply because 
the parasite which produces it is capable of transmission from man to 
man, as also from animals to man, and vice versa. It is often conveyed 
to man from mice, cats, dogs, rabbits, fowls, and ponies ; but when 
derived from the lower animals is most often transmitted from mice to 
cats and from cats to man. It shares with other diseases originating 
from vegetable parasites the peculiarity of attacking certain individuals 



826 



PARASITIC AFFECTIONS. 



specially predisposed to such invasion, either by reason of physical 
peculiarities of organization or because of accidental and fortuitous cir- 
cumstances. It is most common from infancy to the thirtieth year of 
life. It is less common in the United States, Austria, and England 
than in France, Scotland, and Poland. It is said by Bergeron 1 to be a 
disease of the country, while tinea trichophytina prevails in the cities. 
This statement is corroborated by general experience. Favus is more 
common in public than in private practice, and the larger number of 
clinical patients with favus come to the city from the country. 

Fig. 89. 




Achorion Schonleinii : a, spores ; b, c, sporophores. (After Cornil and Ranviee.) 

Evidences of contagion are exhibited in those cases in which several 
members of the same household are affected with the disease ; but in 
other cases the absence of a history of contagion after exposure indi- 
cates the relative difficulty experienced in propagating the contagious 
element in the case of favus. Thus, one individual exposed among 
a dozen who are diseased will fail to exhibit favus-crusts ; and the 
latter by no means form in all situations of the same body where the 
fungus can be discovered by the microscope. Aubert, 2 indeed, presents 
an argument in favor of the production of the disease by traumatism, 
the resulting wounds, excoriations, etc., becoming by accident the seat 
of the disease. It is not very rarely discovered under poultices and 
fomentations. 

Occasionally favus occurs in special localities with such development 
among men and the inferior animals as to constitute an epidemic. 
Girard 3 reports thus the simultaneous existence of the disease among 
sixteen cows and four children in the village of Nantoin, in France. 
It is propagated also upon the skin of rats and mice, from which it is 
transmitted to man, often through the medium of the domesticated cat 
and dog. 

Pathology. — Under the microscope the fungus is readily recognized 
in the root-sheaths, the bulbs, and the shafts of the hairy filaments near 

1 Etude sur la Geographie et la Prophylaxie des Teignes, Paris, 1865. 

2 "Kole de Traumatism dans l'Etiologie de la Teigne faveuse," Annales, 1881, s. 2, 
ii., p. 289. 

3 Lyon med., 1880, xxxv., p. 547. 



TINEA FAVOSA. 827 

the scalp. At a distance of about two inches from the bulb the para- 
site ceases to appear in the tissue of the hair. It is also seen upon the 
free surface of the skin. The favus-crust, softened by the addition of 
a little water or solution of potassium hydroxide, may be placed upon 
the slide of the microscope without other preparation for its study. The 
hairs may be examined in the same manner or they may be stained by 
the methods given for staining the ringworm fungi. Under a good 
one-fourth- or one-sixth-inch objective the vegetation is seen to be 
composed of intricate masses of mycelium and spores in great 
quantity. 

Quincke 1 attempted to distinguish between three varieties of the 
favus fungus, designated respectively as a, /3, and y. Elsenberg, Krai, 
Pick, Unna, and others have, however, arrived at different conclusions 
upon the same subject, some recognizing but two of Quincke's forms ; 
others, two separate forms not corresponding with the «, /?, or y form 
of Quincke ; and still others, corresponding with none of those pre- 
viously described. The majority of observers agree that there is but 
one achorion fungus, displaying itself in several forms both under the 
microscope and clinically, all differences being due to accidental influ- 
ences (varying amount of heat, moisture, and friction in the involved 
surface). 

The threads of the fungus usually preponderate, and appear as nar- 
row, flattened, ramifying, short or elongated, linear cells or tubes, 
which may be simple and empty, or be divided more or less regularly 
by transverse partition-walls, transforming the longer and simple into 
shorter and compound cells. The latter often contain in their cavities 
sporules clinging to either side, in which case the mycelial threads are 
termed sporophores. These sporules are the vegetative part of the 
cryptogamous fungus, and develop by multiple subdivision into cells, 
which may also themselves similarly increase in number, or by the 
production, at the terminal extremities of certain mycelial threads, 
of spores or conidia. The conidia are encapsulated or are strung 
like beads upon a necklace, and they appear as round, oval-shaped, 
angular, or very irregularly contoured bodies, often provided with 
partition-walls like mycelium, constituting thus compound cells. At 
the same time an amorphous granular matter can usually be distin- 
guished in the mass of the fungus. The hyphse vary in width from 
0.0023 to 0.0030 mm.; and the spores from 0.0023 to 0.0052 mm. 

Examination of the invaded scalp reveals, according to Unna, 2 the 
presence of the fungus at the lower border of the upper three-fourths 
of the root-sheaths, where chains of conidia appear among the histo- 
logical elements. His view is that the cuticle of the hair offers a rela- 
tive resistance to the growth of the vegetation ; that the latter first 
penetrates the stratum corneum and the follicular orifice, and then 
stretches, upon the one hand, into the cortex and medulla through the 
cuticle of the hair ; and, on the other hand, passes to the inner root- 
sheaths, the outer remaining always intact. In the epidermis the 
fungus is found chiefly between the superficial and deep portions of the 

1 Monatshefte, 1889, viii., p. 49. 

2 Vierteljahr., vii., p. 170. 



828 PARASITIC AFFECTIONS. 

stratum corneum. The superior pars vascularis of the corium exhibits 
enlarged vessels surrounded by inflammatory elements. 

When the nail is involved the parasite may be recognized in the 
debris produced by scraping the nail-substance ; often also in the epi- 
dermis bordering the nail. The fungus exhibits here the same micro- 
scopical features as upon the scalp, though in consequence of the denser 
structure of the nail-substance its vegetation is usually less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, which in 
all typical cases are isolated, each pierced by a pilary filament and each 
situated in a well-marked depression of the surface of the scalp. In 
the disseminated form the disks of conglomerated scutella with defined 
and frequently festooned edges, friable, yellowish or yellowish white 
in color, and greatly differing as to their bulk and contour, are com- 
monly suggestive of the nature of the disorder. In yet other irregu- 
larly formed crusts the affected area seems to be covered with a plaster- 
like mass irregularly distributed and of uneven thickness over an 
enormous patch of disease which may be practically coextensive with 
the entire scalp-surface. Incidentally there may be a history of con- 
tagion and a peculiar odor emanating from the scalp. The secondary 
effects upon the hairs, hair-follicles, and skin are also, when present, 
significant. White, of Boston, in an essay on the " Vegetable Para- 
sites, and Diseases caused by their Growth upon Man," calls attention 
to the stage in which the disease is likely to be mistaken for ringworm. 
It exists before the formation of the crust, and may be characterized 
by hyperemia, vesiculation, or papulation, often unnoticed beneath the 
hairs of the scalp. In doubtful cases the microscope will usually estab- 
lish the diagnosis, though Bodin, Morris, Sabouraud, and other 
observers think it is not always possible to draw a sharp line between 
favus and ringworm, and that cases occur in which it is impossible — 
with the means now at our disposal— to make a differential diagnosis 
with precision. 1 

Aubert, 2 in the absence of the clinical features named above, lays 
stress upon an intense redness of the scalp where the hairs have been 
cut and the crusts removed, this color being limited to the portions at- 
tacked by the disease. The hairs also, as a result of disintegration 
of their elements, are infiltrated with air, and look opaque and black by 
transmitted light ; by reflected light they appear polished and stratified, 
as if constituted of layers of tissue. It should not be forgotten that 
in exceptional cases favus-crusts coexist upon the body with other dis- 
eases of prior or of subsequent origin, as indicated. The disease should 
not be confounded with seborrhcea, pustular eczema, or psoriasis of the 
scalp, none of which exhibits the special features of a parasitic fungus. 

Treatment. — The first indication in the treatment of favus is to 
cleanse the affected surface from all crusts and scales that may be 
present, For this purpose the scalp (if this be, for example, the 
affected part) is first shorn of its hair with scissors, and is then thor- 

1 For literature of this subject, see Mewborn, Jour. Cutan. Dis., 1903, xxi., p. 11 
(illustrations and bibliography), and the references tabulated with the introductory 
paragraphs on Ringworm. 

2 Annales, 1881, s. 2, ii., p. 34. 



TINEA FAVOSA. 829 

oughly soaked with olive-, cod-liver, or other oil, or with glycerin. 
After this treatment all the crusts are scraped away with a spatula, 
and the scalp is washed clean with hot water and soap, spirit of green 
soap being here preferably used. The scalp should then again be 
anointed with oil or be covered with an emollient poultice. Once thor- 
oughly cleansed by repeated soakings with oil and by ablutions, it is 
necessary to resort either to the topical employment of parasiticides 
(agents capable of destroying the fungus) or to epilation (extraction 
of the hairs). Often both measures are required. Without further 
treatment the scalp, however completely freed from all evidences of 
the disease, will not fail to show fresh favus-crusts in a fortnight or 
somewhat longer time. 

Epilation is practised with the aid of epilating-forceps. These for- 
ceps should be constructed with an easy spring that will not tire the 
fingers of the operator ; with blades that are sufficiently broad to grasp 
a few hairs at once ; and with smooth or but slightly serrated faces of 
the blades, as otherwise the hair is liable to fracture in the grasp of the in- 
strument. The surface to be operated upon should previously be anointed 
with vaselin or with olive-oil, and the hairs entirely be removed, a suf- 
ficient number, covering a definite space, upon successive days. 

The tediousness of this process has led to several devices by which, 
it is sought to do away with its necessity. Originally the " calotte " 
was employed for the removal of the hairs ; it was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk twitch with the 
hand the hairs which adhered were forcibly uprooted en masse; 
those remaining being adherent in their sacs in consequence of the 
fact that they had not been invaded by the fungus. As a substi- 
tute for this procedure, Bulkley l employed adhesive masses or sticks, 
which can be melted and be made to adhere at once to large numbers 
of the hairs. When cold they can be withdrawn from the surface 
with the hairs attached. These sticks are from two to three inches in 
length, and from one-fourth to three-fourths of an inch in diameter. 
The hair is first clipped so as to be about one-eighth of an inch in 
length. The end of the stick is then heated in an alcoholic flame, 
and quickly placed upon the scalp. It is thus left in place until cold, 
and is removed by bending it over and drawing upon the hairs suc- 
cessively with slight rotation. When free it is found thickly set with 
the extracted filaments, which may be burned off in the alcohol flame, 
thus destroying both the hairs and any adherent fungous masses. The 
stick is then carefully wiped clean with paper, after which it is again 
ready for use. The formula for the mass of which these sticks are 
composed is as follows : 

R 



lu Favu 
p. 1496. 



Ceree flavae, 




3iij ; 


12 




Laccse in tubulis, 




3iv; 


16 




Kesinse, 




3vj; 


24 




Picis Burgundicse, 




3xj; 


44 




Gummi dammar., 




Bjss; 


45 


M. 


and its Treatment by a 


New 


Method of Depilation," 


Arch, of Derm., 1881, 



830 PARASITIC AFFECTIONS. 

Removal of the hair may be accomplished by the use of the ;r-rays. 
The danger of producing permanent alopecia is slight unless the 
treatment be continued longer than necessary to produce a single 
removal of the hair. In a few instances the treatment has given per- 
manent relief from the disease, but, as a rule, this reappears with the 
new growth of hair. 

The parasiticides in greatest favor are : corrosive sublimate in solu- 
tion in the strength of from 1 to 4 grains (0.066-0.266) to the ounce 
(30.) ; formalin (1 to 4 per cent.) ; sodium hyposulphite in saturated 
solution ; pure or diluted sulphurous acid ; spirit of green soap ; chry- 
sarobin, pyrogallol, tar, croton-oil ; boric, carbolic, and salicylic acids ; 
petroleum, chloroform, ether, creosote, and oil of cloves. The addi- 
tion of acetic acid to liquid applications, or washing the surface with 
vinegar immediately before applying the parasiticide, favors penetration 
of the remedy. Ointments are also useful containing mercury (citrin 
ointment, yellow sulphate, or. white precipitate), naphtol, benzol, thy- 
mol, sulphur, pyrogallol, salicylic and carbolic acids. Chrysarobin 
is effective in an ointment, though objectionable on account of the 
staining of the scalp, and, almost inevitably, of the face also. Lenz- 
berg * generates sulphur-fumes in a dish of red-hot coals attached to a 
frame (made of wood or of pasteboard) close to the head of the patient. 
By means of a paper cap the fumes are collected and retained (from 
five to ten minutes) in contact with the patient's hair. During ten 
years' trial of this plan he has never been compelled to resort to 
epilation. 

One or more of the methods may be needed, either at the same time 
or by repetition or alternation, until the fungus is entirely destroyed, 
the requisite period usually extending over three months. Treatment 
should then be discontinued in order to test the result by observation. 
If, in the course of a fortnight or more, a relapse occurs, treatment is 
to be promptly renewed. Upon the non-hairy portions of the body 
parasiticides thoroughly applied usually insure radical relief. When 
the nail is involved, it should be cut short and carefully scraped or be 
softened by repeated applications of a strongly alkaline lotion, after 
which a parasiticide may be employed in ointment or lotion. 

In general, it may be remarked that patients long affected with 
rebellious favus may need a roborant course of treatment and nu- 
tritious diet. Cleanliness here, as in all the parasitic disorders, is 
important. As adjuvants in the treatment of the scalp and nails it is 
well to remember that continuous applications of a parasiticide are 
aided by caps or cots of impermeable material superimposed upon rags 
saturated with the medicament employed. For use in this manner, and 
especially for the nails, Sabouraud recommends a solution containing 1 
gramme of iodine and 2 grammes of potassium iodide in a litre of dis- 
tilled water. 2 

Prognosis. — The prognosis is generally favorable to the ultimate 
termination of the disease in all cases ; for even the most rebellious 
and untreated forms are relieved when the hair- follicles atrophy. Upon 

1 Der prakt. Arzt., February, 1881. 

2 See paragraphs at the close of the chapter on Ringworm. 



TINEA TRICHOPHYTINA. 831 

the non-hairy portions of the body the disorder is rarely severe if 
promptly and efficiently treated. Upon the scalp the prognosis is pro- 
portioned to the extent, severity, and period of prior invasion of the 
disease. Early and vigorous treatment of the scalp in healthy children 
is usually followed by satisfactory results. In long-neglected subjects 
of the disorder the result may be a remediless and characteristic bald- 
ness, the affected surface being provided with scanty wisps of stunted 
and uncolored hairs. Neglect, filth, and systemic malnutrition are the 
most unfavorable elements in any case. 

TINEA TRICHOPHYTINA. 

(Gr. dpi!;, hair ; <j>vrov } a vegetation.) 

(Bjngwokm.) 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and the beard, as also of the non-hairy portions of the body. In each 
case it is produced by the presence of a vegetable fungus. Until re- 
cently all forms of ringworm, both of the hairy and non-hairy portions 
of the body, were supposed to be produced by a single fungus, the 
trichophyton. In 1891 Furthmann and Neebe first advanced the idea 
that there were two or more fungi responsible for the various mani- 
festations of the disease. Within the last few years a number of in- 
vestigators, headed by Sabouraud, in a series of researches, have more 
definitely settled the etiological value of these fungi. 1 There are at 
least two distinct and unrelated forms capable of producing the 
appearances classed as ringworm : the Microsporon Audouini, or 
small-spored fungus, and the Trichophyton, or large-spored fungus. 
Of the latter, several varieties are recognized. The microsporon appears 
under the microscope chiefly in the form of a large number of round 
spores, irregularly grouped or massed about the follicular portion of the 
hair. Mycelial threads, large and branching, are also seen, chiefly within 
the hair. The sheath of spores surrounding the hair is often continued 
upward about the latter for one-sixteenth or one-eighth of an inch 
above its exit from the follicle, and in this situation can be recognized 
by the unaided eye as a whitish or grayish coating of the hair. 

The mycelial threads of the microsporon are all within the hair 
proper, and after repeatedly dividing and subdividing they terminate 
on the outer surface of the shaft in fine filaments, at the extremities of 
which are the spores, which in this fungus are external. In France 

1 Sabouraud, Les Trichophyties humaines, with Atlas, Paris, 1894 ; Diagnostic et 
traitement de la pelade et des teignes de 1' enfant, Paris, 1905 ; La Pratique Dermatolo- 
gique, iv., p. 467; Adamson, Brit. Jour. Derm., 1895, vii., pp. 201, 238 and 373; 
Morris, Practitioner, Aug., 1895 ; Kingworm and the Trichophyton, London, 1896 ; 
Fox and Blaxall, Brit. Jour. Derm., 1896, viii., pp. 241, 291 and 337, and Brit. Med. 
Jour., 1899, ii., p. 1529 ; Transactions of Third International Congress of Dermatology, 
London, Aug. 4 to 8, 1896, including papers by Sabouraud, Kosenbach, and Morris ; 
Kosenbach, " Ueber die tieferen eiternden Schimmelerkrankungen der Haut," Wiesba- 
den, 1894 ; Leslie Boberts, Brit. Thera p. Jour., Sept. 29, 1894,_ and Jour. Path, and 
Bact., Aug., 1895. (This observer classifies the fungi according to their ability to 
digest horny tissues.) M. Fadyen, Jour. Path, and Bact., April, 1895; Jamieson, Brit. 
Med. Jour., Aug. 20, 1893 ; Bodin, Des Teignes tondantes du cheval et leur inocula- 
tions humaines, Paris, 1896; Mibelli, Annales, 1895, s. 3, p. 733; Charles J. White, 
Jour. Cutan. Dis., 1899, xvii., p. 1. 



832 PARASITIC AFFECTIONS. 

the microsporon is responsible for about 60 per cent, of all cases of 
ringworm of the scalp in children. The fungus is not found in ring- 
worm of the beard or of the body except in the form of small, irreg- 
ularly outlined, slightly reddened, and furfuraceous patches, occurring 
on the face and neck in children having ringworm of the scalp ; occa- 
sionally on the skin of adults who come in contact with such children. 
Such lesions of the skin do not at all resemble ordinary ringworm, as 
their outlines are irregular and ill defined, and they rarely persist for 
more than a few days at a time. Iu France the microsporon is rarely, 
if ever, found in kerion. 

The trichophyton is composed of spores which vary greatly in size, 
but which, as a rule, are considerably larger than those of the micro- 
sporon. They are frequently cuboidal, oval, or irregularly rounded ; 
but their chief characteristic lies in the arrangement in lines or chains 
extending up and down the hair-shaft. The mycelium is found without 
but never within the hairs. The trichophyton occurs in three varie- 
ties : the endothrix, in which the spores occur wholly within ; the ecto- 
thrix, in which the spores are distributed wholly without ; and the endo- 
ectothrix, in which the spores are partly within and partly without the 
hair. The endothrix, like the microsporon, is found chiefly in ring- 
worm of the scalp of children, though it also may produce transient, 
inconspicuous, irregular, furfuraceous, and slightly reddened patches 
on the face and neck of children affected with this form of ringworm. 
On the scalp the endothrix produces lesions which are often distinctly 
different from those caused by the microsporon. These differences are 
noted in the clinical description of tinea tonsurans. The ectothrix and 
the endo-ectothrix apparently are derived either directly or indirectly 
from the domestic animals, and are responsible for ringworm of the 
body, of the beard, and of all suppurating forms of the disease. 1 By 
means of culture-experiments a number of subvarieties of the tricho- 
phyton are differentiated, many of which, however, are not generally 
accepted. These varied appearances are looked upon by some as the 
result largely or wholly of differences in the media and circum- 
stances of cultivation. It is well known that slight modifications of 
the culture-media produce marked changes in the character of a fungus- 
growth. Under certain conditions the trichophytons may assume forms 
indistinguishable under the microscope from those of tinea favosa. 2 

In London, Morris, Fox, Adamson, and others find that the micro- 
sporon is responsible for more than 90 per cent, of all cases of ring- 
worm of the scalp in children, and that it also occurs in some cases of 
ringworm of the body, and even in some of the suppurating forms of 
the disease, as kerion. The trichophyton is comparatively rare in Lon- 
don. On the other hand, Mibelli states that the microsporon is almost 
unknown in some parts of Italy, and it would seem to be equally rare 
in some portions of Germany. In Boston Dr. Charles J. White found 
the microsporon in 139 out of 279 cases of ringworm examined. The 
different varieties of these fungi seem to have a definite geographical 
distribution. 

1 Boclin reports four cases of superficial svcosis due to endothrix alone (Annales, 
1900, s. 4, i., p. 1205). 

2 Cf. Mewborn, Jour. Cutan. Dis., 1903, xxi., p. 11 (bibliography). 



PLATE XXX. 



Fig. 1. 




Portion of a Hair showing the Mierosporon Audouini. 

(From a photo-micrograph.) 



Fig. 2. 




Portion of a Hair invaded by the Trichophyton, 
Endo-eetothrix. x SOO. 

a, a— Chains of spores in focus, b— A. chain situated further within the hair, and hence not in focus. 

(From a photo-micrograph.) 



TINEA TRICHOPHYTINA. 833 

To prepare a hair for examination, it may be placed between a 
slide and cover-glass in a solution of potassium hydroxide. Sabouraud 
uses a 25 to 40 per cent, solution, which is admirable for rapid work, 
but which quickly disintegrates the hair. Adamson employs a 5 or 10 
per cent, solution, which clears the hair slowly in the course of one or 
several hours. By making frequent examinations of the specimen the 
observer can arrest the destructive action of the solution at any stage 
desired, and thus better preserve the relative position of the fungus to 
the hair. Many attempts have been made to stain the fungi, which 
unfortunately show an affinity for the same stains as does the cortical 
layer of the hair. A satisfactory method has been devised by 
Morris and his laboratory assistant, Calhoun. It is a modification of 
the Gram and AVeigert stain for bacilli, and gives good results. The 
hair is first washed with ether to remove fatty debris ; it is then put for 
one or two minutes in the Gram iodine solution, and after drying is 
stained for from one to five minutes in gentian-violet and anilin-water. 
It is again dried and treated for a minute or two with the iodine solu- 
tion, and for an equal length of time in anilin-oil containing pure iodine, 
after which it is cleared with anilin-oil, washed in xylol, and mounted 
in Canada balsam. Coarse, dark hairs and spores within the hairs 
require more time for staining than do fine, light-colored hairs and the 
fungus-elements situated without the hair. 

While microscopical examination will often suffice to distinguish 
the microsporon from the trichophyton, or even for recognition of some 
of the varieties of the latter, the finer — and often disputed — points of 
diiFerence can be appreciated only by means of culture-experiments, 
the details of which require fuller description than can here be 
given. 

Recent studies of the ringworm fungus, though interesting from 
an etiological standpoint, have added little knowledge of practical 
value in treatment of the disease, nor have they furnished a basis for a 
new and scientific classification of the different forms of ringworm. 

As the several regions of the body, when invaded by the parasite, 
display lesions which are more or less peculiar to itself, it is usual to 
consider each separately. Ringworm of the body is, therefore, desig- 
nated Tinea Circtnata ; of the scalp, Tinea Tonsurans ; of the 
beard, Tinea Sycosis. 

Tinea Oircinata. 

(Herpes Tonsurans, Ringworm of the Body. Ger., Scheerende 
Flechte ; Fr., Herpes circine, Tricophytie.) 

Symptoms. — Ringworm of the body displays different symptoms 
according to the temperature in which the vegetation flourishes and 
the various external irritants to which the skin where it has once been 
implanted is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or of several pea- to large coin-sized, circumscribed, reddish 
circles, usually paling under pressure, often at the general level of the 
53 



834 PARASITIC AFFECTIONS. 

integument, occasionally slightly raised above it, forming then a flat- 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye be unaffected, transforming the patch to an annular lesion, 
from which circumstance it originally received the name " ringworm." 
It develops within certain limits, rarely exceeding five or six inches in 
diameter, by peripheral extension ; and is usually characterized at the 
outer border by slight, whitish, furfuraceous desquamation. This form 
of lesion is usually seen upon exposed surfaces of the body where there 
is less heat, moisture, and friction than upon other parts, as, for exam- 
ple, the forehead and neck in moderate atmospheric temperatures. 
From it may be developed the other forms described below. The 
disease may recur within the peripheral border ; in this way occasionally 
two, three, or more concentric rings or parallel bands of crescentic 
outline may be visible in a single patch of disease. Frequently a ten- 
dency to a peculiar formation, often that of concentric circles, is found 
in every patch existing at the same time in a given case. It is possible 
that the various types are produced by different species of the fungus. 
The subjective sensations are a trifling degree of itching or of burning. 
Should these rings extend to the beard or the scalp, the circinate may 
coexist with the other varieties of the disease. 

The vesicular lesions of ringworm appear as such at the onset, or 
they rise from the macular lesions described above. In the former 
case pin-point-sized, transitory, and superficial vesicles or vesico- 
papules spring from a central point or focus, or speedily shrivel until 
they are represented merely by minute, whitish, branny scales. To 
these lesions others succeed, always at the periphery, and to these again 
yet others, the rosy or the reddened base on which they rest being 
sometimes slightly in advance toward the outlying skin. The enlarg- 
ing circlets of disease proceed in their course to an evolution similar to 
that observed in the macular forms. The difference, due to a more 
active development of the fungus, is noted not merely in the type of 
the lesion, but also in the slightly exaggerated pruritic sensations 
that are awakened. Rarely, both of the forms described are pre- 
sented with acute symptoms and extensive development, in multiple 
patches spreading over the face, neck, trunk, and extremities, accom- 
panied by a slight febrile movement and moderate tumefaction of 
the affected surfaces. As a rule, the eruption is trifling, and may, in- 
deed, be limited to a single ring, or to a few circlets about the neck, 
terminating in the branny desquamation described ; but in the severer 
forms the evolution of the disease may persist for months and crusts 
form, the fall of which leaves annular pigmentations of temporary 
duration. 

The papular and rare pustular forms of the disease observe the same 
peculiarities with respect to the clearing of the centre, the annular 
appearance of the advancing area of involvement, and the production 
finally of scales and crusts. They represent, however, either a much 
more luxuriant vegetation of the fungus, or the irritation of the affected 
part by friction and heat, or, what is probable, the cooperation of the 
two. They are, hence, most commonly observed upon the back, the 
belly, the intermammary and inframammary regions, and the inner 



TINEA TRICHO PHY TINA. 835 

faces of the thighs and arms, iu which localities they occasionally 
occur with chronic manifestations. The papules are light- or dull-red- 
dish, pinhead-sized and larger, solid elevations, roundish, oval-shaped, 
irregular, or confluent, forming eventually bean- to coin-sized, raised 
disks with a pale, exfoliating, or actively inflamed centre, the so-called 

NUMMULAR ERYTHEMA, or DISCOID TRICHOPHYTIC ERYTHEMA of 

French authors. Some of the cases of Conglomerate or Agminate 
Folliculitis are due to the trichophyton. 1 The itching in these forms 
is sometimes severe ; and the process may display central recrudescence, 
as noted above. Pustules found at the periphery have the size and 
distribution of the other lesions described. They represent merely 
an aggravated exudative process awakened by the fungus and the 
scratching incident to the pruritic sensations excited. 

Eczema Marginatum, Tinea Trickophytina Cruris. — Partly 
because of the controversy which the subject aroused, special attention 
was once directed to this variant of the disease which Hebra was first 
to describe. It is most marked upon those portions of the body which 
come in contact with the saddle when a rider is mounted on a horse — 
that is, the perineum and the inner faces of the thighs, the region 
marked by the reinforcing patch in the trousers of the cavalry- 
man. The disease, as encountered here, occurs in both sexes. It is 
characterized by extensive exudation in bright or lurid patches, with a 
very distinctly defined, raised border, showing a sharp contrast with 
the healthy skin beyond, from which peculiarity it has its name. It 
may extend laterally over the groins upw r ard over the pubes, and back- 
ward over the sacrum, being generally defined at the periphery by a 
crescentic outline. The centre may be paler and less involved, or 
actively irritated, while the periphery still extends in one or more 
annular festoons down the inner side of the thigh or upward over 
the regions indicated. The itching is severe ; the course of the dis- 
ease is obstinate, persistent, and subject in a remarkable degree to 
relapse in the same locality. The fungus is always present, whether 
occurring as a cause or an epiphenomenon of the disorder. The dis- 
ease was rightly named by Hebra, and it deserves special recognition 
under whatever title it may be classified. It is a true eczema, with 
special features, complicated by the development of the trichophyton, 
and, as is now well known, often by other representatives of the " der- 
matological flora. " It is aggravated by heat, the moisture of sweat, 
and the friction of apposed surfaces of the skin in contact with 
each other and the clothing. After detecting the fungus in scales 
scraped from the surfaces thus involved, one is always in such cases 
impressed with the characteristic clinical peculiarities of the disease. 
It is usually of symmetrical distribution, due to the circumstances of 
its development, and in this respect differs from the other manifesta- 
tions of the disease. The condition may occur in milder or even 
severe forms in the axilla or about the breasts of women or about 
the umbilicus. In such cases it is indistinguishable clinically from 
a disorder described by Vidal under the title Circinatf and Mar- 
ginate Pityriasis (pityriasis circine et margine), which he regards as 
due to microsporon anomceon, or dispar. 

1 Cf. Schamberg, Jour. Cutan. Dis., 1902, xx., p. 410 (review of published cases). 



836 PARASITIC AFFECTIONS. 

Tinea Trichophytina Unguium (Onychomycosis). — When the 
nails are affected they become friable, opaque, and lamellated ; and 
are clinically indistinguishable from nails secondarily changed in favus, 
eczema, psoriasis, and similar disorders of the integument. One or 
several of the nails of both the feet and hands may be involved. 
When all the nails of both extremities are invaded the disease is rarely 
of parasitic origin. The microscope is requisite for establishing the 
diagnosis in the latter case, the parasite being detected in the frag- 
ments procured by scraping the nail. . 

Etiology. — Tinea circinata is caused by the presence of the parasite, 
though the parasitic invasion may be an accident of other cutaneous 
disorders. The trichophyton was first- discovered in 1844 by 
Gruby \ though Malmsten, whose name is often associated with that 
of the fungus, became identified with its recognition by his observa- 
tions during the succeeding year. As a contagious disease it ranks 
higher in the scale than favus, being much more readily communicated, 
and, as a result, much more common. Occurring upon the non-hairy 
portions of the body, it is often spontaneously removed by the desquam- 
ative process which it excites in the skin. 

Though the fungus is the essential cause of the disease, its develop- 
ment is greatly favored or retarded by external influences. Attention 
has already been called to its luxuriance under the influence of heat 
and moisture. It is, therefore, much more severe and rebellious to 
treatment in tropical countries. It occasionally occurs in epidemic 
forms. Thus, Gerlier 1 gives the details of such an epidemic in Fer- 
ney Voltaire, where twenty-six cases of the disease came under his 
observation. In some of these instances the lesions were pustular, 
in other tuberculo-pustular. Aggravated forms of the disease often 
originate in the lower animals, the severest and most rebellious 
types being derived usually from the horse. Tinea circinata oc- 
curs much more frequently in children than in adults, presumably 
from the relatively tender condition of the epidermis in these subjects. 
It is particularly liable to occur in men whose skins are especially 
moistened, as in those who work in atmospheres saturated with steam. 
Several members of a single household will often display ringworm 
of the body at the same time, having transmitted it the one to the 
other. The need of an appropriate soil for the germination of the 
fungus is shown by the fact that some individuals are predisposed to 
its invasion. It is, however, encountered in both sexes and in all 
social conditions. 

Pathology. — The seat of the fungus in tinea circinata is between the 
strata of the epidermis, more particularly in the lower layers of the 
stratum corneum and in the superior layers of the rete. Here the 
trichophyton can be recognized with the microscope, at an early stage 
of the disease, in the form of spores only ; in the course of a few 
weeks exhibiting characteristic mycelium. The latter is much more 
scantily developed than in favus ; much less branched and articular ; 
and the threads more slender. Like the elements in favus, however, 
these are jointed and divided into compound cells by partition-walls. 
1 Lyon med., 1881, xxxvi., p. 599, and xxxvii., p. 7. 



TINEA TRICHOPHYTINA. 



837 



The spores are also often strung like beads on a necklace. The former 
measure 0.0018 to 0.0026 mm.; and the latter, 0.0021 to 0.0035 mm. 
(Duhring). 

After the fungus has found its way to the surface of the skin favor- 
able to its development it penetrates the layers of the epidermis in 
every direction from the central point of invasion, the circle thus pro- 
duced being characteristic of many forms in both the higher and the 
lower vegetable life. The irritation excited by the presence of this 
foreign body produces all the subsequent symptoms of a mild grade of 
superficially seated inflammation : erythema, exudation, minute vesicles, 
papules, and, in severe grades, tubercles and pustules. The desquama- 
tive symptoms represent, in a sense, the natural effort at relief; 
this effort, as noted above, being often successful when the spores and 
sporophores are thrown off with the effete, horny plates of the epi- 
dermis. When the nails are affected the fungus can be discovered 
in detritus of the nail-tissue which has been macerated in dilute 
liquor potassse. Sabouraud states that only the different species 
of trichophyton, ectothrix pure, or endo-ectothrix, are found in ring- 
worm of the glabrous skin and of the nails, though the trichophyton 
endothrix and the microsporon Audouini may be found occasionally 
in small, irregular, transient, reddened, slightly furfuraceous areas 
occurring on the face, neck, and other parts of the body during the 
course of ringworm of the scalp. 

Fig. 90. 




Epidermis invaded by trichophyton : a, inferior portion of the stratum corneum ; b, superior 
portion of the rete. Both exhibit long mycelial threads, with a few ramifications and a small 
number of spores. (Kaposi.) 



Diagnosis. — Ringworm of the body is to be distinguished, clinically, 
from eczema, psoriasis, seborrhoea, lupus erythematosus, herpes iris, and 
syphilis. All the varieties of eczema are noted for their greater degree 
of itching and infiltration, their much less defined border, coarser 



838 PARASITIC AFFECTIONS. 

scales, decided absence of a circular contour and of a history of con- 
tagion. Psoriasis does occur in circular and annular patches, often 
with a clear centre and insignificant, subjective sensations ; but its scales 
are lustrous and the tissue beneath them readily bleeds, showing 
deeper implication of the skin. The disease is often symmetrical in 
disposition ; occurs by preference upon certain regions of the body 
where ringworm is relatively infrequent ; and its history is that of a 
chronic disorder. Seborrhoea of the skin exhibits greasy or fatty crusts, 
which are never characterized by the peculiarly branny scales seen in 
ringworm of the body. (The distinction between these disorders on 
the scalp is given under Tinea tonsurans.) Lupus erythematosus is 
often symmetrical, generally chronic, and is characterized by the develop- 
ment of multiple annular patches, enlarging centrifugally from a clear- 
ing centre. Herpes iris can be distinguished, first, by its predilection 
for the extremities ; second, by the color-variegations which it displays 
and which are never seen in ringworm of the hands. Syphilis is mul- 
tiform in its lesions, usually preceded by a history of infection ; and 
its distinctly circular patches, enlarging at the periphery, all exhibit 
either atrophic, ulcerative, or distinctly crusted lesions which suffice 
for diagnostic purposes. 

Pityriasis rosea is not characterized by vesicles ; is often symmet- 
rical in development ; occurs in oval rather than in distinctly circular 
patches ; and exhibits a characteristic tawny-yellowish shade of color 
not seen in ringworm. In eczema marginatum the elevated border and 
infiltration of the diseased surface, its situation (groins, armpits, pubes, 
etc.), its curved outlines, and the occurrence of fresh rings within the 
older, point to the nature of the trouble, which is practically a coexist- 
ence of ringworm and dermatitis. 

But the microscopical discovery of the parasite is the chief, and, 
indeed, the essential, method of diagnosis in tinea circinata. With 
a good fourth- or fifth-inch objective the spores and mycelium are 
readily recognized in the scales scraped from the affected surface 
and moistened with dilute liquor potassse. Care should be had in 
distinguishing the fungous elements from cotton- or wool-fibres, fat- 
globules derived from previously applied unguents for the cure of the 
disease, sebum, pus, and the nuclei of epithelia. All confusion of this 
sort can be avoided by a careful study of the anatomical peculiarities of 
the trichophyton, recalling especially the parallelism seen in the double 
contours of the threads, their jointed appearance, their contained 
granules, and the necklace-like or beaded arrangement of many spores. 

Treatment. — The indications in the treatment of ringworm of the 
body are the removal of the superficial layers of the epidermis, by 
which means the spores and mycelium are thrown off from the surface ; 
and, if possible, the simultaneous destruction of the latter. Upon the 
delicate skins of infants and children the simpler remedies are first to 
be employed. Scrubbing each patch with spirit of green soap, or merely 
soap and water, will often suffice for its obliteration. The topical ap- 
plication of tincture of iodine is a common and usually an effective 
remedy. The same may be said of dilute acetic, boric, and carbolic 
acids, or of a 1 or 2 per cent, solution of formalin. A solution of acetic 



TINEA TRICHOPHYTINA. 839 

acid used with or immediately before other parasiticides is said to favor 
penetration of the latter. Morris's solution of thymol, 1 \ drachm to 2 
drachms (2.-8.) of chloroform and 6 drachms (24.) of olive-oil, is equally 
available. One may also use thymol in ointments, -|- drachm (2.) to 
the ounce (30.) of simple unguent, with good effect. A 1 to 2 per cent, 
solution of formalin is often effective. Of the mercurials, ammoniated 
mercury, 1 scruple (1 .33) to the ounce (30.) of ointment ; corrosive sub- 
limate, 1 to 2 grains (0.066-0.133) to the ounce (30.) of solution ; and 
the ointment of mercuric nitrate, 1 drachm (4.) to the ounce (30.) of 
vaselin, are valuable. Sulphurous acid, from a freshly opened can, and 
saturated solutions of sodium hyposulphite are as effective as any of 
the parasiticides, and are often used with advantage as lotions, to be 
followed by an appropriate unguent, always providing against chemical 
decomposition of the ingredients of the latter. Sulphur- and tar-con- 
taining lotions and unguents are useful in more obstinate cases. 

Chrysarobin and pyrogallol, in ointment, from 5 to 10 grains (0.33- 
0.66) to the ounce (30.), are brilliantly effective in all these cases, sub- 
ject, however, to the disadvantage incidental to the staining and irri- 
tative effects they produce. They should be used with caution upon 
the skins of children, and always tentatively at the onset. In cases of 
ringworm of the face of male adults, close to the beard or the scalp, one 
may employ these remedies with a view to insure non-invasion of the 
pilary follicles by the fungus, the prompt destruction of which may 
become then a matter of urgency. Wilkinson's ointment recommended 
by Kaposi is also useful in the treatment of aggravated forms of ring- 
worm of the body, but it should be restricted to such forms. For other 
and more urgent reasons potassium hydroxide solutions should be re- 
served for exceedingly intractable cases. Sometimes a combination of 
several of the simpler remedies named above may be serviceable, as in 
the following formula? : 

R Lac. sulphur., Sijss ; 10 

Sapon. virid. spts., } - - _ . . -- 24 

Lavandul. tr., } aa 3v 3 ' aa i4 



Glycerin., 3 SS 



M. 

[Kaposi.] 



R lodin. pur., Jij ; 601 

01. picis [sp. gr. 0.853], § j ; 30] M. 

Mix with care, gradually. 

R Creasoti, n\,xx; 1 

01. cadini, f Siij ; 12 



Sulphuris prsecip., f 3hj : 12 

Potass, bicarb., 3j ; 4 

Adipis, £j ; 30 



M. 



To be used in obstinate ringworm of adults. 



[Van Harlingen.] 



E. W. Taylor applies mercuric chloride, 4 grains to the ounce 
(0.26-30.) in tincture of myrrh. Perry, of California, uses the bichlor- 
ide in one-half the strength last named, dissolved in sulphuric ether. 
1 Lancet, 1881, L, pp. 164 and 241. 



840 PARASITIC AFFECTIONS. 

Foulis, of Edinburgh, recommends iodine dissolved in oil of turpentine 
or benzin, the fluids named penetrating with greater ease than others 
to the deeper portions of the skin. 

Other articles advised are oleates of mercury and copper, croton-oil, 
glacial acetic acid, cantharidal collodion, petroleum, and pyroligneous 
acid (Thomas). 

The thorough application of the remedy selected for use, upon 
the integument freed from scales by scrubbing with soap and water, 
is a matter of importance. When a solution of sodium hyposulphite 
is employed, the previous application of vinegar and water by 
sponging renders the agent more effective, for evident chemical 
reasons. Over-treated skins, or those to which too strong a parasiti- 
cide has been applied, require subsequent relief of the induced irrita- 
tion by the simpler bland dressings. The inert dusting-powders, even 
when not thus indicated, are often useful when there is distinct 
vesiculation ; and in simple cases they may be the sole remedies re- 
quired, as then the disease is self-limited in duration. 

The internal treatment of patients affected with ringworm, by means 
of tonics and roborant measures, may be demanded by the systemic 
condition, but it has no recognized influence over the disease itself. 

When the nails are involved, they should be thoroughly scraped 
and then kept moist by wearing the rubber cots sold for the use of 
sportsmen, fishermen, and others. In this way a partial maceration of 
the nail-substance is secured, and the action of any one of the para- 
siticides named above is greatly aided. One of the solutions most 
useful in the treatment of the nails is that recommended by Sabouraud, 
containing 1 gramme of iodine and 2 grammes of potassium iodide in 
a litre of distilled water. 

Prognosis. — The disease is often self-limited, and is generally 
under the simplest treatment satisfactorily relieved. Eczema margi- 
natum, especially in the crural region, may be obstinate, because it is an 
eczema as well as a parasitic disease, and, therefore, subject to the re- 
lapsed and chronic phases of the first-named disorder. Other intract- 
able forms of the malady do, however, occasionally occur in adults, 
usually in tropical climates and tropical temperatures. 

Tinea Tonsurans. 

(RlNGWORM OF THE SCALP, HERPES TONSURANS, TlNEA TONDENS. 

Ger., Scheerende Flechte ; Fr., Teigne Tondante.) 

Ringworm of the scalp is a disease chiefly of children, and occurs 
most frequently among those congregated in public institutions. The 
gregarious habits of children and the frequency and intimate character 
of contacts in their amusements and studies greatly increase the 
chances of contagion when one of their number is affected with ring- 
worm of the scalp. As a consequence, the early recognition and 
relief of the disease furnish problems among the most imperious pre- 
sented to the general practitioner as well as to the dermatologist. 
Important considerations relating to the segregation and education 



TINEA TRICHOPHYTINA. 841 

of children are related to the question of treatment. Nor should the 
physician, examining and giving advice about the scalp of a number 
of children, forget that his hands may transmit the disease to those as 
yet unaffected. 

Symptoms. — The differences to be particularly noted between ring- 
worm of the body and ringworm of the scalp depend largely upon the 
fact that in the latter the fungus makes its way to the hair-follicles 
and there finds the nutriment for its multiplication and development. 
The symptoms usually first observed are circumscribed, small coin-sized, 
roundish patches upon the scalp, wholly or partly covered with minute, 
whitish, slate-colored, grayish, or dirty-yellowish scales. Sometimes 
the formation of the scales can be observed as they develop upon a 
hypersemic and reddened area. Still more rarely, pin-point-sized, 
transitory vesicles or pustules precede. The hairs upon such a patch 
seem irregularly clipped short near the surface or, as it is frequently 
styled, " nibbled " off, thus producing the effect of partial baldness in 
the involved area. Among them may often be found lustreless, dry, 
long and fragile hairs, which break upon slight traction or flexion. 
The patches may increase in number and spread individually in area 
until, in the course of weeks or months, the entire scalp is invaded. 
In the older patches young and downy hairs may here and there be 
seen, pushing up the stumps left by those that have fallen. One or 
more of various phases of the disease may be presented in its subse- 
quent evolution. Thus, a single patch may extend to the size of that 
of a large coin or of the palm, and the disease be throughout limited to 
that area. Again, as set forth above, almost the entire scalp may be 
covered with relatively small or enlarging patches, or, even without the 
occurrence of any distinct patch, isolated hairs or tufts of hairs here 
and there over the entire scalp may exhibit evidence of impairment. 
The hairs, instead of " starting" from the patch, may be twisted, 
imbricated, or matted, and be covered with grayish scales. The disease 
may be acute or be chronic in its course. Instead of assuming the dry 
and squamous type described, acute and exudative symptoms may de- 
velop, in which event the rare vesicular and pustular lesions are suc- 
ceeded by the exudation of a gummy secretion and the formation of 
crusts. Lastly, there may be produced the variety known as " kerion," 
which is described below. 

Pruritus, in various grades of severity, though usually mild, is in- 
duced by the disease ; and often the patches are altered in appearance 
by the traumatisms produced by the finger-nails and the comb. When 
the scalp is very generally invaded by the squamous form of the dis- 
order its appearance is very similar to that noted in diffuse seborrhoea, 
chronic eczema, and psoriasis of the scalp, except that the hairs are 
less pasted to the surface ; are more lustreless, friable, and contorted 
in shape ; and much more often are represented by stubble or stumps. 
The disease may occur coincidently with ringworm of the body, and 
indeed at times there may be detected a ring, half of which on the 
neck presents the typical aspect of tinea circinata, and the other half 
involving the scalp exhibits the features here described. 

Stowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and 
1 Lancet, 1881, i., p. 326. - Ibid., 1880, i., p. 425. 



842 PARASITIC AFFECTIONS. 

others, have recorded cases in which the disease coexisted with alopecia 
areata. Geber asserts that after exfoliation of patches of ringworm the 
scalp may, in cases, become absolutely bald, smooth, and glossy. This 
condition may exist from the beginning in the Bald Tinea Tonsurans 
of Liveing, which is often mistaken for alopecia areata, an error readily 
corrected by the recognition of scaling patches with hairs exhibiting 
under the microscope evidences of the existence of the fungus. It is 
to be remembered that in all such persistent scaling patches left after 
treated or untreated ringworm of the scalp the possibility of contagion 
is not averted. 

The Disseminated Ringworm of Alder Smith affects isolated 
hairs or small groups of hairs scattered over the scalp, a broken stump, 
or a group, or a relatively small number, of lustreless, dry, and friable 
hairs furnishing the only evidence of the disease. 

Ringworm produced by the microsporon Audouini can often be 
distinguished clinically from that produced by the trichophyton. In 
the former the patches are single or few in number, are rounded 
or oval in outline, may be of considerable size, are usually slightly 
reddened and furfuraceous, and are more or less covered with hairs 
which are lustreless, dirty looking, broken off at irregular distances 
from the surface, and easily epilated between the thumb and finger 
in considerable numbers. Moreover, in this form a grayish or 
whitish sheath (composed of spores) is seen encircling each hair 
and extending from one to three millimetres above its exit from 
the follicle. In patches of ringworm produced by the trichophyton, 
according to these observers, the patches are much more numerous, but 
are very small and irregular in outline, and instead of being covered 
by hairs and broken stumps of hairs, usually show a number of black 
dots at the mouths of the follicles caused by the breaking of the hair at 
or beneath the surface of the skin. In this latter form of ringworm 
the scalp itself is usually normal or nearly so, scaling not being usual ; 
and, instead of forming patches, the disease may affect isolated hairs 
or small groups of hairs. The disseminated ringworm and the 
bald tinea tonsurans mentioned above are probably produced by 
the trichophyton, and not by the small-spored fungus. It is un- 
doubtedly true that the clinical differences mentioned above can be 
noted in some cases, and the diagnosis made at once from a simple 
inspection of the affected areas. In the majority of cases, however, 
the clinical features are not sharply marked, and the diagnosis must 
rest upon microscopical examination, or even upon culture-experiments. 

Lastly, it is to be noted that in tinea tonsurans at times the efforts 
of nature are successful in obtaining spontaneous relief. With the 
defluvium capillitii and exfoliating epidermal plates the fungus may 
finally be removed ; the resulting alopecia be followed by a growth of 
healthy pilary filaments ; and, even though years be required for this 
long process, in the end no trace of the disease be discernible. 

Etiology. — Ringworm of the scalp is produced by the fungus 
recognized in the etiology of tinea circinata, the trichophyton, or by 
microsporon Audouini (see introductory paragraphs on Ringworm). 
Ringworm is observed frequently in children of both sexes, especially 



TINEA TRICHOPHYTINA. 



843 



in those gathered together in schools and public charities, where it may 
spread very generally from one to another, and require months and 
years for its extermination. It is a highly contagious disease, but yet 
requires unquestionably a suitable soil for its development. White 1 
calls attention to the fact that when there is ringworm on the face of 
an adult, even of rebellious form, in the course of which the beard may 
be affected extensively, the scalp usually is spared. Ringworm in the 
scalp of the adult and the aged is, indeed, among the rarest of cuta- 
neous accidents. Among the methods of transmission in children are 
the use upon the head of the unaffected of brushes, combs, wearing- 
apparel, sponges, towels, etc., which have been employed upon persons 
exhibiting ringworm of the body or the head. It must be remembered 
that tinea circinata may transmit tinea tonsurans ; and it is by tracing 
the course of the two forms of the disease that the sources of contagion 
can be ascertained in any series of cases. The disease is one rather pre- 
vailing in cities than in the country ; in this respect it differs from favus. 

Pathology. — The disease is produced in consequence of invasion 
of the scalp and follicles, bulbs, and shafts of the hair by the fungus 
already described. 

Under the microscope the hairs are seen to be greatly altered 
in advanced cases (Fig. 91). The bulbs are distorted, misshapen, 



Fig. 91. 




'&38BP$gsw&& 



2'rV 



*&%^ 



Hair invaded by the trichophyton. 



or withered, and often stuffed with spores which greatly predomi- 
nate over the mycelium. At times the base of the bulb will show 
a brush-like expansion, and in this respect resembles the free ends of 
the stumps of the hairs above, which have a jagged, bristle-like appear- 
ance, from division of the shaft into many filaments between which 
spores in abundance are visible. The shaft is often longitudinally split 
where the parasitic growth has mechanically forced apart its elements, 
and its cuticle may be peeled off or curled above and below away 
from the axis, with spores protruding at such points. Conidia can 
be discovered much further upward along the hair and distant from 

1 Loc. cit. 



844 PARASITIC AFFECTIONS. 

the scalp than in favus ; often, indeed, upon its free surface. Occa- 
sionally a few mycelial threads may be recognized, either longitudinally 
or transversely arranged as regards the axis. It is probable, however, 
that the relative preponderance of spores and mycelium in these fila- 
ments is determined by the stadium of the disease in any given case. 
In the earlier stages of the affection the elongated threads may be dis- 
covered in larger quantity, and, as they interfere less with the integrity 
of the fibrous tissue, the hair usually at these times may be extracted 
from its follicle without fracture. Later, the threads disappear and the 
conidia are infiltrated throughout every portion of the shaft, which 
then breaks often upon the slightest traction. One unaccustomed to 
microscopical examinations with a view to the detection of the parasite 
should be careful not to mistake for these threads the delicate lines 
which traverse the surface of the shaft exposed to the objective, and 
which represent the edges of the cuticle of the hair. In doubtful cases 
the hair should be examined in liquor potassse and after staining by the 
methods given in the first pages devoted to the subject of ringworm. 
The scales found upon the affected scalp also exhibit traces of the para- 
site under the microscope, though to a less extent than the invaded 
hairs. In exceptional cases, however, the epidermis of the scalp seems 
to suffer as much as that of the non-hairy portions of the body. 

As to the mode of invasion, it is still disputed whether the spores 
find access to the fundus of the follicle between the shaft and the 
follicular wall, or by penetrating the cuticle of the hair-shaft at the 
level of the epidermis. It is possible that invasion may occur in both 
ways. 

Diagnosis. — The recognition of a typical patch of ringworm of the 
head is simple. The branny scales, clumps of hairs, and distinct con- 
tour of the invaded area are always in the highest degree suspicious 
symptoms. It has been stated, however, that the general development 
of tinea tonsurans over the scalp produces a condition very like that 
seen in other diseases. In this case the microscope must be employed 
for a decision as to the nature of the process. The whole vertex has 
been unnecessarily epilated in seborrhoea sicca when no parasite could 
be found ; but in seborrhoea there is usually a symmetry of involvement 
which even aggravated cases of ringworm of the head fail to assume ; 
and even though pasted down, atrophied, changed in color, and loos- 
ened in their follicles, the hairs are rarely broken off near the scalp in 
seborrhoea. In seborrhoea, psoriasis, and squamous eczema of the scalp 
there is, moreover, no history of contagion ; the scales are in each 
disease different in color and character ; and the hairs in the two affec- 
tions last named are firmly fixed in their follicles, and only in severe 
cases present nutritional changes. The diseases, moreover, are usually 
chronic in their course. In any doubtful case, apart from microscopical 
evidence, thorough removal of all scales from the scalp by shampooing 
with green soap and hot water will reveal the nature of the disease 
present. 

Alopecia areata, as has been noted above, may coexist with ring- 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, and the hair falls from them 



TINEA TRICHOPHYTINA. 845 

en masse without scaling or other traces of previous involvement of the 
regions affected. Blackish points or dots may, however, be distributed 
over the areas which characterize this form of alopecia, and which cer- 
tainly constitute suspicious symptoms in any case. In this event one 
may at times be able to pick out with a fine needle this blackish point 
from the patent follicular orifice, and find it to be a particle of dust 
accidentally lodged in the depression. It is not, as in comedo, free 
pigment that has found its way to the surface ; nor, as in ringworm, is 
it the stump of a hair on a level with the surface of the scalp. In favus 
the cup-shaped, crust will sooner or later betray the character of the 
disease to the naked eye. 

Confirmatory evidence as to the nature of the disease will often be 
furnished by a careful search for the source from which it was derived ; 
and for obvious reasons this should always be attempted. Ringworm 
of the body occurring upon the individual patient affected with tinea 
tonsurans, or upon other members of the same household, and suspi- 
cious " mangy " patches upon horses, dogs, cats, rabbits, white mice, or 
other animals with which the child may have been in contact, should 
always receive attention. 

Treatment. — The indication for the relief of the disease is the de- 
struction of the parasite ; and there can be no question that this may be 
accomplished in some cases without having recourse to epilation. The 
parasiticides named in connection with ringworm of the body, if thor- 
oughly applied in simple cases, after clipping or shaving the hair and 
efficient scrubbing of the patch with spirit of green soap and water, 
will occasionally be followed by permanent relief. Prominent among 
these parasiticides may be named formalin (1 to 5 per cent, in aqueous 
solution), pyroligneous acid, sulphurous, acetic, salicylic, and boric acids, 
saturated solutions of sodium hyposulphite, acetum cantharidis, tincture 
of iodine ; Crocker's ointment containing thymol, 1 part to 4 ; Morris's 
solution of thymol in chloroform and olive-oil (see Tinea circinata) ; 
and ointments of boric acid and sulphur, of each 1 drachm (4.) to the 
ounce (30.) of vaselin, and chrysarobin, the action of the latter being 
carefully limited to the patch of disease by the aid of a skull-cap. 

Epilation, however, is a valuable, and often an essential, method of 
treating the disease, and it may be practised as recommended when 
considering the treatment of favus. The scalp in each case should 
first be oiled, and be cleansed by the soap-shampoo, and after the epi- 
lation is performed an appropriate parasiticide should be employed. 
The calotte, made by spreading pitch-plaster upon leather or muslin, is 
a clumsy substitute for epilation in order to remove the hairs, but the 
sticks recommended by Bulkley may be employed, the formula for the 
preparation of which has already been given. In each case the epila- 
tion should remove a zone of sound hairs encircling the diseased patch, 
that the encroachments of the fungus may in every possible way be 
limited. It should not be forgotten, however, in the treatment of 
tinea tonsurans by both epilation and parasiticides that in chronic 
cases these methods in the hands of the most expert have failed for 
consecutive months to relieve radically the disease ; that even the most 
inveterate cases, in the course of time and as adult years are reached, 



846 PARASITIC AFFECTIONS. 

are relieved spontaneously without permanent alopecia ; and that no 
remedy or procedure is ever justifiable which is capable of either pro- 
ducing follicular atrophy or an effect worse than that wrought by the 
disease itself. The #-rays may be used, as in favus, to remove the 
hair. As a rule symptoms of the disease reappear with the new growth 
of hair, but in a few instances the treatment has been effectual in over- 
coming the disease. 

Jackson l recommends an ointment containing a drachm (4.) of iodine 
crystals in an ounce (30.) of goose grease. This is rubbed into the scalp 
twice a day until swelling is produced. An alopecia follows, but the hair 
returns. Leven 2 applies oil of turpentine on linen twice a day for a 
week, or until inflammation occurs. Exfoliation follows, the subsequent 
treatment being the application of a simple ointment. Hodara 3 applies 
daily, after shaving the hair, from 5 to 10 per cent, of chrysarobin in 
equal parts of glycerin and chloroform. On the production of erythema 
and oedema the treatment is suspended until the irritation has subsided, 
and then is renewed. Four or five months are necessary for a cure. 
Sabouraud 4 prescribes the following method : The scalp is shaved and 
the hair epilated from the diseased area and from a zone 4 or 5 mm. 
wide surrounding it. Every second evening the entire scalp is rubbed 
thoroughly with 60 per cent, alcohol containing 25 per cent, of pure 
iodine ; beginning areas of the disease not visible to the unaided eye 
are stained by the iodine and can be recognized easily. On alternate 
evenings an ointment containing pyrogallic acid, 15 grains (1.) ; gil of 
cade, 1. drachm (4.); and vaseline, 5 drachms (20.), is applied. The 
scalp is washed each morning wi'th soap and hot water. If this treat- 
ment fails to produce a follicular inflammation, croton oil is added to 
the ointment. 

Coster's paste is popular among English practitioners, including 
Stowers, Fox, Liveing, and others. It contains 2 drachms (8.) of 
iodine in crystals, dissolved in oil of tar; and is painted over the 
part at intervals of a few days. It is most useful in circumscribed 
patches of the disease. Among other remedies employed, some of 
which have been described in connection with ringworm of the body, 
may be named mercuric chloride, ammonio-chloride, red oxide, oleate, 
and ointment of mercuric nitrate ; epispastics ; pure carbolic acid 
and carbolated glycerin ; sulphur, chloroform, ether, tar in ointment, 
and Wilkinson salve. 

To be effectual the treatment pursued must be persistent and thor- 
ough, and always be accompanied by frequent washings and soapings 
of the affected part. 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion), by the aid of electrolysis and croton-oil liniment, has 
been praised by Alder Smith and Wyndham Cottle, of London, and 
later, in a modified form, by Magee Finny, of Dublin. By the process 
of Finny, 100 parts of the oil are mixed with 50 each of cocoa-butter 

1 N. Y. Med. Kecord, 1902, lxi., p. 164. 

2 Jour. Mai. cutan., 1901, xiii., p. 241. 

3 Monatshefte, 1903, xxxvii., p. 118. 

4 La Pratique Dermatologique, iv., p. 508. 



TINEA TRICH0PHYT1NA. 847 

and white wax. Sticks are made of this compound which can thor- 
oughly be rubbed into the part affected. By both methods it is claimed 
that no pain is produced, nor is permanent alopecia the result. A so- 
lution of salicylic acid is applied after each treatment, and a subsequent 
poultice may also be needed. In these cases the parasite is destroyed 
presumably by the suppuration excited. As in the case of ringworm 
of the body, tinea tonsurans is not remediable by internal treatment. 
Such internal medication, however, may be indicated by the systemic 
condition of young patients, and should be in each instance such as 
that condition suggests. 1 

Prognosis. — The prognosis in every judiciously treated case of 
tinea tonsurans is favorable, since all patients ultimately recover 
from the disease per se. Under the best treatment many cases prove 
extraordinarily tedious, month after month passing without marked 
improvement. The disease, however, in a large proportion of cases 
among children surrounded by proper hygienic conditions, especially 
as regards cleanliness, is readily relieved. 

Tinea Keeion (Keeion Celsi, from xypiov, a honey-comb). — 
The occurrence of active and usually circumscribed inflammation in 
a portion of the scalp affected with ringworm is at times followed by 
certain peculiar features. This complication of ringworm was recog- 
nized early in the history of medicine by Celsus, whose name has 
since been associated with its lesions. Tilbury Fox, in 1866, was first 
to recognize its identity with tinea tonsurans ; and it has since been 
the subject of a number of papers by Tanturri, Maiocchi, Schilling, 
Barduzzi, Au spitz, and Wilson. In the United States Atkinson 2 has 
made it the subject of a memoir. 

The symptoms are the occurrence of acute inflammation, usually 
circumscribed, though occasionally diffuse, in a portion of the scalp, 
where a tumor forms which may project a considerable height above 
the general level. In time the appearance presented is suggestive of 
anthrax benigna, since from the tumid orifices of numerous distended 
follicles a viscid, semitransparent, puriform fluid exudes. The latter 
is characteristic. The hairs loosen and fall. When the view of 
the lesion is not obscured by the pilary growth it appears as a 
flattened hen's-egg- to turkey's-egg-sized, boggy, semiglobular tumor, 
its surface congested, reddened, glazed, and often exhibiting other evi- 
dences of inflammation, with split-pea-sized, pustule-like lesions dis- 
tributed over its surface, or, when these have ruptured, exhibiting the 
gaping apertures described above, from which a gummy secretion is 
poured in varying quantities. Modification of this condition occurs, 
such as the production of a true subcutaneous abscess with fistulous 
sinuses. The sensations awakened are usually painful ; the course of 
the disease is chronic. It may begin with the usual symptoms of ring- 
worm of the head, though often there is no history of the latter. The 
complication is a rare one. 

The parasite may and may not be found in patches of kerion, 

1 See also paragraphs on page 

2 Arch, of Derm., 1881, vii., pp. 47 and 48, 



848 PARASITIC AFFECTIONS. 

according to the acuity of the present or the precedent inflammatory 
process. If the latter be of high grade, and suppuration result, the 
fungus is destroyed, a result the attainment of which has been at- 
tempted in the production of " artificial kerion " by means of croton- 
oil for the relief of tinea tonsurans. In the earlier stages repre- 
sented by deep-seated follicular inflammation, with pustulation of the 
hair-shafts, the latter may be seen microscopically to be invaded with 
spores. 

The treatment is either by the milder parasiticides or by the methods 
proper for the relief of ordinary phlegmonous inflammation of the scalp, 
according to the stage of the kerion. The pus-cocci present in some 
of these cases require boric-acid lotions and bichloride washes. 

Tinea Sycosis; Hyphogenous Sycosis. 

(Tinea Barbae, Sycosis Parasitica, Mentagra Parasitica, 
Bingworm of the Beard, "Barbers' Itch." Ger., Para- 
sitare Bartfinne; Fr., Trichophytie Sycosique.) 

Symptoms. — The disease is best studied at its onset in the beard of 
a blonde subject with relatively fine, downy hairs, where are presented 
the typical features of tinea circinata, ringworm of the body. One or 
several, reddish, pea- to small-coin-sized rings become visible, with pin- 
point-sized vesicles, branny scales, and often, indeed, no other lesion 
save a hyper&emic, scarcely elevated margin at the periphery. The 
hairs over the patch may be fragile, and clusters of pilary filaments here 
and there betray evidences of change. With proper treatment the dis- 
order may not progress beyond this point. 

In some cases the very slight degree of itching awakened by the 
process just described may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or vice versa. When fully developed a phlegmonous 
disorder is produced which bears some analogy to the kerion just de- 
scribed, and which may so actively progress that it is first seen in 
typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifice of the pilary 
follicles, and is studded irregularly with firm, pea- to nut-sized papules 
and tubercles. The tubercles are usually aggregated in masses or lumps 
which involve the skin and subcutaneous tissue, and they are firm, 
often tender and painful, rarely boggy and furuncular. When pierced 
they give exit to a characteristic, muciform, gluey, yellowish, and sticky 
fluid, puriform yet differing from pure pus, that rapidly dries into 
crusts. These composite lesions are usually circumscribed in a given 
area of involvement, very rarely covering the region of the beard in 
symmetrical disposition, more often limited to one cheek or to the 
cheek and chin. 

The hairs in the invaded region are involved as in ringworm of the 
scalp. These filaments break near the surface of the integument, leav- 
ing ragged stumps ; or they spontaneously fall after being loosened in 
their follicles. The ease with which they may be epilated is one of the 
most characteristic features of the disease ; they are slipped out of their 



TINEA TRICHOPHYTINA. 849 

follicles as readily as if they bad been oiled ; or, as Anderson writes, 
" as easily as a pin can be pulled out of a pin-cushion." They are then 
often whitish because enveloped in the fungus producing the disease. 
In either event the resulting gradual thinning or removal of the hairs 
renders the disease of the surface more conspicuous and deforming. At 
the edge of a patch thus exposed, deformed, lustreless, contorted, flat- 
tened, twisted, or split hairs may be found. Occasionally the features 
of the patch are changed in consequence of the unusual degree of sup- 
puration excited. In this case the pustules burst and their contents 
concrete into dry crusts about the stumps of shafts of surviving hairs, 
from which circumstance the disease has received its name (sycosis, 
auxov, a fig). Rarely, a conglomerate crust covers the entire region 
with an excoriated, inflamed, and secreting surface beneath. 

Formidable cases of tinea sycosis have occurred in the persons of 
farmers, where the disease was long untreated and unrecognized. 
Some severe types of the disease have been produced after shearing 
sheep having diseased pelts. In these cases the cheeks, lips, and chin 
are the seat of nut- to fist-sized and larger cutaneous and subcutaneous, 
soft, boggy, and pus-filled tumors, accompanied by excessive soreness 
of the entire throat and neck, the hair falling from the follicles in large 
masses, and as if lubricated to facilitate their escape. 

Etiology. — The disease is produced by the ectothrix or endo-ecto- 
thrix varieties of the trichophyton (see introductory paragraphs on Ring- 
worm). White, of Boston, has called special attention to the frequency 
of its origin in the barber-shop, a fact which common experience verifies. 
It is usually the irregular visitor to these establishments who is first to 
supply the germs of the disease. No individual proprietorship in cup, 
soap, brushes, and razor can secure against the danger of infection the 
person whose razor is drawn over a common strop, whose cheek is 
handled by unwashed fingers which have recently been passed over an 
infected face, or whose beard is combed, brushed, or rubbed with the 
implements and towels in common use at these establishments. The 
remedy is twofold : first, the full beard should be worn without shav- 
ing, as it is rare to find bearded patients of this class affected with tinea 
sycosis ; second, where the whole or any part of the beard is to 
be removed every adult male should shave himself. The physician 
should, in this connection, for medico-legal reasons be upon his guard 
against hastily deciding both as to the nature of the disease of his 
patient and the source from which it was derived. Of the first, he can 
become certain by his microscopical investigations ; of the second, he 
can only be sure by obtaining possession of facts far beyond the reach 
of the average practitioner. A medical gentleman once sent for exami- 
nation some hairs from the beard of a male patient affected with tinea 
sycosis. Before receiving a report confirming the diagnosis this phy- 
sician was sued by the barber in whose establishment the disease had 
been probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from sta- 
tistics. The affection is certainly relatively rare, yet more common 
than is often supposed to be the case. It is of somewhat irregular 
54 



850 



PARASITIC AFFECTIONS. 



occurrence, months often passing without a case coming under obser- 
vation, after which several may be noted in rapid succession. 



Fig. 92. 




Filaments and spores of the trichophyton from the beard of a patient affected with tinea sycosis. 



The disease, being contagious, is one affecting men in all stations 
of life, and these usually at a period rather under than over the fortieth 
year. More men with light hair and eyes, and light-brown, reddish, 
or sandy beard are affected than those having darker shades of hair 
and eyes. Morris has called attention to the fact that tinea tonsurans 1 
occurs more frequently in blonde than in brunette subjects. 

Pathology. — The disease is essentially a follicular and perifollicular 
inflammation induced by the irritative effects of the fungus, precisely 
as in the case of tinea tonsurans. The difference between the clinical 
aspects of the two diseases may be explained in part by the habitual 
covering of the scalp with caps and hats while the face is left exposed ; 
and by the occurrence of tinea sycosis in adult years, while tinea ton- 
surans is predominantly a disease of childhood. As a result of the 
induced inflammation, vesicles, pustules, papules, and tubercles are 
formed, while the perifollicular inflammation may invade all portions 
of the skin and subcutaneous tissues, gluing together the plastic nod- 
ules formed about the individual hair-sacs into the lumpy masses char- 
acteristic of the disease. The invasion of the hair-follicles and hairs 
by the fungus is accomplished as in the case of ringworm of the scalp. 
Under the microscope spores and mycelium are visible, the forms pre- 
ponderating at the time when the disease first comes under observation, 
but probably preceded in most cases by abundance of thread-like forms. 
The identity of the disease with some forms of ringworm of the body 
and scalp does not, however, rest merely upon microscopical observa- 
tion; but is demonstrable by established clinical facts. Not only may 
1 Lancet, 1881, pp. 164 and 241. 



TINEA TRICHOPHYTINA. 851 

ringworm be seen to spread from the face to the beard, but tinea ton- 
surans and tinea circinata may also transmit tinea sycosis, and the 
reverse. A physician had ringworm of the bearded chin and cheek 
derived from the face of a child under his care. He subsequently 
gave tinea circinata to his wife, who suffered on the face and shoulder, 
and she, in turn, communicated tinea tonsurans to her daughter. Such 
cases, however, are unusual (see introductory paragraphs on Ringworm). 

Diagnosis. — The distinction between coccogenous and hyphogenous 
sycosis is of chief importance in this connection ; and, necessarily, the 
microscope must be employed to settle the question definitely. The 
diseases, however, differ in their clinical features. The coccogenous 
form always fails to exhibit the nodules, tubercles, and composite cuta- 
neous and subcutaneous agglutinations of the disease produced by the 
fungus. The process in the former is more superficial, and it exhibits 
to the eye a more vivid redness as a result of the cutaneous hyperemia. 
Owing to the same cause, the frequent pus-containing lesions are de- 
veloped and elevated above the general level of the integument ; they 
are less commonly subepidermic crypts filled with characteristic mucoid 
puriform contents. The region of the bearded upper lip, so often 
involved in cases of nasal catarrh, is often spared by the tri- 
chophyton.- When this parasite is present the hairs are characteris- 
tically loosened, distorted, and otherwise changed. This condition 
is not seen in the coccogenous disease ; exception, however, in this 
particular is to be noted in some long-standing cases of the latter. 
When the affection has persisted for many years (and one may often 
see patients thus affected) the thinned and starved condition of the 
pilary growth is a striking symptom, the scanty lustreless hairs 
often scarcely sufficing to conceal the deforming redness and pustula- 
tion of the surface from which they spring. The diffuse symmetrical 
affection of the hairy face, extending over both cheeks and chin, is 
more frequently connected with the presence of pus-cocci. Lastly, the 
hyphogenous, as a rule, is less painful and tender than the other form 
of sycosis, and, furthermore, is, without question of rarer occurrence. 

With respect to syphilis, it is to be noted that the papular or the 
pustular syphiloderm developed in the region of the beard is, almost 
without exception, to be discovered in other parts of the body, especi- 
ally the scalp. Ringworm of the scalp and the beard existing at the 
same time in one individual is rare. In syphilis there is usually an 
offensive odor to the abundant crusts ; shallow ulcers are also prone 
to form beneath the pustules ; and there is often a history of infection 
or a hint of the nature of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other portions 
of the face, as in a case in which it sweeps from the ear above. The 
presence of a stalactitic crust depending from the lobe of the ear of 
an affected side would at once furnish a clue to the nature of the 
disease in the beard. In eczema the interfollicular region is invaded, 
not deeply, as in tinea, but superficially, as in coccogenous sycosis. 
The itching is severe ; 'the hairs are not involved ; the infiltration is 
diffuse ; the outline is indeterminate ; and a halo of redness spreads 
from the affected part to the non-hairy surface in the vicinity. 



852 PARASITIC AFFECTIONS. 

Treatment. — The treatment of tinea sycosis is conducted generally 
as in tinea tonsurans. It is customary to begin by anointing the 
affected surface with an oily or fatty substance, and to follow this with 
a shampoo of soap and warm water for the removal of crusts, after 
w T hich shaving and epilation are practised on alternate days ; and para- 
siticides employed locally. For softening the crusts the spray of an 
atomizer may be used. 

Epilation of the male beard is often essential for removal of the 
disease, but the results of the treatment suggested below in the end 
may be satisfactory. 

The patient for two successive days keeps the affected part macerated 
with almond- or olive-oil. On the evening of the third day the sham- 
poo with soap is employed, and the skin is washed free from crusts and 
scales. The part is then cleanly shaved. This operation is at first 
painful, but gradually becomes less distressing. After shaving, the 
affected surface is bathed for ten minutes with borated water as hot as 
can be tolerated, by which means the inflammatory condition of the 
perifollicular tissues is, in a brief time, considerably reduced. While 
the bathing is in progress all subepidermic pustules or points where a 
mucoid fluid is coming to the surface are opened with a fine aseptic 
needle. A solution of sodium hyposulphite is then sponged freely 
over the affected surface for several minutes and allowed to dry ; 
this solution may contain 1 drachm (4.) to the ounce (30.), or even 
more. After a thorough and final washing with hot water the tender 
skin is carefully dried and gently smeared with a sulphur ointment 
containing 1 to 2 drachms of sulphur (4.-8.) to the ounce (30.) of 
vaselin, often with the addition of from J to J (0.016-0.033) grain of 
mercuric sulphide. The patient then retires to bed. In the morning 
the unguent is washed off with soap and water, the sodium-solution 
is reapplied, and a borated or a salicylated powder is thoroughly dusted 
and kept over the part during the day. In the evening the shaving 
may be repeated or not, according to the vigor with which the beard 
is reproduced, but on the second day shaving is imperative. As soon 
as the pustulation ceases and the tubercles have manifestly diminished 
in size the ointment at night is superseded by the use, at that time 
also, of the dusting-powder. Whether the shaving is practised nightly 
or on alternate nights, ablution with very hot water and with solution 
of sodium hyposulphite is continued nightly until the inflammation 
excited by the fungus is practically limited to the follicles that are 
invaded. The dusting-powder is to be thoroughly and constantly 
employed after the ointment is discontinued. With care and patience 
these measures may save many patients the annoyance of epilation ; 
and they should be continued for several weeks after apparent relief 
of the disease. 

The treatment may be varied to suit the needs of individual cases. 
Kaposi highly recommends, for example, 1 per cent, solutions of cor- 
rosive sublimate locally ; and the other parasiticides considered here- 
tofore in connection with the treatment of ringworm may serve also a 
good purpose. In some cases an ointment of thymol may be used with 
manifest advantage ; in others, a substitute may be found in Morris's 



TINEA IMBRICATA. 853 

solution of the same in chloroform and oil (the formula for this has 
already been given). In still other cases spirit of green soap with 
sulphur, finely powdered sulphur, boric, acetic, and carbolic acids, or 
other topical applications of recognized value may be employed. 

When resort is had to epilation, and this is essential in all severe 
cases, the hairs should be thoroughly removed from their follicles over 
every lumpy nodule, and even over every suspicions patch covered 
with scales. A zone should be cleared about each such papule. The 
results are prompt and in the highest degree satisfactory. 

Prognosis. — This disease is always remedied sooner or later, though 
it is at times tedious in its progress and characterized by relapses. 

Precautions to be Observed in the General Management of 
Tinea Favosa and Tinea Trichophytina. 1 — The physician consulted 
in the case of a patient affected with either of the diseases thus far 
considered as resulting from the presence of a vegetable parasite should 
bear in mind that they are the most contagious of their class. He may 
not only himself suffer from the disease which he is attempting to 
relieve in another, but may also convey it to others, or be consulted 
by others of his patient's family actually infected during the course of 
the treatment pursued. 

Generally, it may be said that the hands of the physician should 
carefully be washed after each manipulation of the part, and preferably 
with a weak disinfecting solution. In the case of children the lining 
of all caps, hoods, and other coverings of the head should be removed 
and destroyed by burning ; and fresh linings made of tissue-paper re- 
newed daily ; while paper-caps of the same or of similar material should 
be worn when indoors. Brushes, combs, towels, and articles of cloth- 
ing should never be used in common by two or more individuals. 
When practicable, infected individuals should occupy separate beds ; 
and the bed-covering, clothing, toilet-apparatus, and dressing or other 
materials which have been in contact with a diseased surface should be 
immersed in boiling water before they are again employed for any use 
in common. Thin recommends covering every diseased patch, after 
the treatment appropriate to itself, with an adhesive and impermeable 
dressing, for the sake, not of the patient, but of those with whom the 
latter may be brought in contact ; and the suggestion is both wise and 
practicable. A man infected with ringworm of the beard in a barber- 
shop Avhich he has visited but once, will often, when directed by his 
physician to shave, resort to some other establishment, Avhere he is well 
known, and where he has more confidence in the cleanliness of the 
operators. In this way he often thoughtlessly spreads the disease of 
which he is the victim. It is well to send patients who cannot shave 
themselves to a particular barber, who, being instructed in the manner 
of shaving so as to insure immunity, generally fails to spread the 
disease in any case. 

1 Cf. Corlett, Jour. Cutan. Dis., 1900, xviii., pp. 315 and 360 (discussion before the 
American Derniatological Association). 



854 PARASITIC AFFECTIONS. 



TINEA IMBRICATA. 

(Tokelau King worm ; Burmese, Chinese, or India Ringworm ; 
bowditch-island or scaly rlngworm, lafa tokelau, plta, 
Cascadoe, Gune, Herpes Desquamans, Tinea Circinata 
Tropica, Gogo. Ft., Herpes tonsurans desqamatif.) 

This disorder was portrayed first by Alibert in 1832, and de- 
scribed first in 1844 by Fox, and has been studied since by Turner, 1 
Manson, 2 MacGregor, 3 Koniger, 4 Roux, and others. 5 It is a malady 
due to the presence of a vegetable parasite and is found chiefly in the 
South Sea Islands and those of the Malay Archipelago. It has been 
recognized also in isolated cases both in India and China. 

Symptoms. — The disease is first declared, after artificial inoculation, 
by a period of delay (" incubation ") lasting about nine days, after 
which minute reddish points appear, arranged for the most part in 
semicircles, the former rapidly developing into papules producing an 
intolerable pruritus. The growth thenceforward is reported to be at 
the rate of from five to ten millimetres each week. In a brief time 
lamellae of epidermis are detached, their free border being directed to 
the centre of the circular disk, the patch or patches when fully de- 
veloped being represented by concentric rings, about five millimetres 
apart, suggesting a resemblance to " watered silk." The scales may be 
as large square as half a centimetre, with curling edges which later 
become horny and much darker in color. It is said that the hand 
passed over such patches from the circumference to the centre recog- 
nizes a smoothness of the surface, but when the motion is reversed, 
from centre to periphery, the scales are raised and resist the fingers. 
The appearance of the older patches suggests a skin covered with 
clay. The process of production of the concentric rings is reported 
to be, first, by the elevation of a central point of the epidermis and 
the formation there by the fungus of a brownish mass ; then by sep- 
aration of the epidermis at the central point, with persistence for a 
time of attachments at the border; then by liberation of the attached 
edge by friction or otherwise ; and finally by exposure of the corium. 
Just beyond this line a brownish rim declares the line of advance of 
the fungus beneath the epidermis. When the ring thus formed has 
attained a diameter of about five millimetres, a brown point again 
appears centrally, and there is a repetition of the process originally 
observed in the primary ring. 

All portions of the body and large areas of the general surface may 
be affected ; but the scalp, face, palms and soles, axilla?, and nails 
seem usually to be spared ; when the hairy parts (scalp, pubes, axillae) 
are involved, the disease spares the follicles, and its management is 
thus declared to be correspondingly facile. Though the hairs them- 

1 Glasgow Med. Jour., 1870, p. 502. 

2 Tropical Diseases, p. 628 ; China Imp. Merit. Cut. Med. Eep., 1879, xvi., p. 1; 
Med. Times and Gazette, 1879, h\, p. 342. 

3 Glasgow Med. Jour., 1876, p. 343 . 

4 Virchow's Archiv, 1878, lxxii., p. 413. 

5 For bibliography, see Scheube, Diseases of Warm Countries, p. 526. 



TINEA IMBRICATA. 855 

selves are not invaded, they are said to fall when the disease extends 
over the hairy regions of the body. When the disease spontaneously 
disappears from any portion of the integument there are left persistent, 
deep-colored rings or circles where the scaling originally occurred. 

The itching is commonly intense ; the scales at times (and in places 
relatively inaccessible to the hands in scratching, such as over the inter- 
scapular region) may be half an inch in diameter and from one-eighth 
to half an inch apart. When bulky and corneous, they give to the body 
the aspect of being clay-coated. The patches may extend at the rate 
of from one-quarter to a half of an inch each week. A somewhat 
characteristic u piebald " appearance is produced in places where the 
scales have been removed and the resulting pigmentation is partial. 
The scaling is most marked in parts contiguous to healthy skin. The 
disorder is exceedingly chronic in career, but is modified, especially in 
its pruritic symptoms, when occurring in milder climates. 

Etiology. — Tinea Imbricata is a contagious disorder affecting per- 
sons of both sexes and all ages, and is produced by a vegetable parasite. 
The disease in certain localities is endemic. It has been produced by 
experimental transmission from a diseased to a healthy skin. 

Pathology. — The fungus recognized in microscopic examination of 
the scales from a morbid patch after moistening with liquor potassse, 
resembles that of the trichophyton. Sabouraud and Nieuwenhuis 
believe it to be a variety of the large-spored trichophyton. Tribondeau 
reports that it is not a trichophyton, but an aspergillus, termed by him 
lepiclophyton. The growth of the organism is in the lower epidermis, 
sparing, however, the hair-pouches. The mycelium is thick and inter- 
laced, compounded of short, rounded segments which branch dichoto- 
mously. It has been cultivated on nutrient media. The spores are 
oval, pigmented in dark-reddish hues, and irregularly contoured. The 
proportion of spores to mycelium differs in different observations, prob- 
ably as a result of the different age of the specimens under examina- 
tion. As the fungus does not perish in the regions invaded, it burrows 
rapidly beneath the newly formed epidermis as soon as the latter is 
formed. In this way Manson explains the features of concentric 
scaling and the persistence of the disease. 

The Diagnosis from " Giant Ringworm," " Boatman's Ringworm/' 
" Dhabie's Itch," " Majee's Dad " — forms of trichophyton as it occurs 
in luxuriant vegetation upon the smooth portions of the body in 
tropical countries — is made readily. In these forms of ringworm the 
central area clears, while in tinea imbricata the central part of the 
patch is made up of concentric rings. The recognition of the parasite 
is essential. 

Treatment. — The scales are removed readily with soap and water 
or by alkaline baths, and chrysarobin, pyrogallol, or iodine ointment 
(Manson advocates strong linimentum iodi) is well rubbed into the 
part. In some cases strong lotions are employed of the same chemical 
constitution. The clothing of the patient should be boiled if not de- 
stroyed by burning. 

The Prognosis is favorable. 



856 PARASITIC AFFECTIONS. 

DHOBIE ITOH. 

("Dhobie," washerman.) 

("Dermatitis Mycotica, Dermatitis Tropica, "Crutch-Itch.") 

The term " Dhobie itch " is employed loosely in several tropical 
countries to designate epiphytic diseases of the skin that are due 
unquestionably to different effective agents. The word is of common 
usage in the Philippine Islands which have become part of the territory 
of the United States, and the result now is that the name is heard occa- 
sionally on the lips of patients in America. 

Three types of infection are known by the names given above : 
one produced by the trichophyton ; one by microsporon minutissimum 
(erythrasma) ; and one bacterial, a form of pemphigus contagiosus. 
It is reported that these affections are introduced into the United 
States by soldiers returning from tropical service where clothing is 
cleansed without boiling. 

Manson 1 believes that the popular idea of the method of contract- 
ing the disease is not well founded. He adds to the list given above 
cases of tinea versicolor. The instances of Dhobie itch coming under 
our observation have been few, and these represented non-mycotic 
cutaneous pruritus. 

The suffering from the affections designated by the term Dhobie 
itch, is said to be severe in tropical countries, and the disease is often 
productive of a high grade of dermatitis. The affected regions are 
liable to become the seat of secondary bacterial invasion. The skin in 
almost all cases is dry, pigmented, and covered with scales. 

Treatment. — Parasiticides are required in all cases, especially Vlem- 
inckx's solution (Manson), linimentum iodi, tincture of the leaves of 
cassia alata, and chrysophanic acid. Solutions of mercuric chloride, 
1 : 1000, are also valuable. 

Prophylaxis is secured by the wearing of short cotton bathing- 
drawers (" swimming trunks ") changed daily and followed by dusting 
powders over the fork of the thighs, composed of boric acid, starch, 
and zinc oxide. 

TINEA VERSICOLOR. 

(Pityriasis Versicolor, Dermatomycosis Furfuracea, Mycosis 
Microsporia, Chloasma. Ger., Kleinenflechte.) 

Symptoms. — The eruption in this disorder occurs in the form of 
few or of many, irregular, roundish, circumscribed or reticulated 
macules, pinhead- to small-coin-sized, rarely occupying an area the 
size of the palm or larger. In color it varies from the most delicate 
buff or fawn shade to a reddish, deep-brown, and even blackish hue. 
The surface of each lesion, when closely inspected, is usually seen to 
be covered with furfuraceous scales. If the scales are not visible, 
slight erasion with the finger-nail or the curette will demonstrate the 
fact that the superficial layers of the stratum corneum are, in the site 
of each lesion, readily separable from the tissues beneath. The eruption 

1 Manson, N. Y. Med. Jour., 1903, lxxviii., p. 221, and Tropical Diseases, p. 625. 



TINEA VERSICOLOR 857 

is most common upon the anterior surface of the thorax ; but it is dis- 
played also upon the neck, the dorsum, the abdomen, and the other 
regions of the trunk, and the flexor aspects of the upper extremities 
(the hands only excepted). It rarely is seen upon the lower extremi- 
ties ; still more rarely on the face ; never on the hands and feet. 1 The 
eruption is either unproductive of sensation or is accompanied by a 
mild pruritus. Patients usually declare that after profuse sweating, 
bathing in warm water, or brisk friction of the surface minute epi- 
dermal rolls separate from the affected area. The disease may linger 
for years upon the surface of the body. It has a special tendency in 
susceptible individuals to recur after removal. 

The eruption is occasionally encountered in extreme development. 
In a young married woman who had been the subject of the disease for 
many years the entire trunk, the axillae, the groins, the upper portion 
of the thighs, the neck to the level of the high collar worn, and the 
upper extremities to the wrists, were encased in a uniform sheet or 
cuirass of chocolate-tinted epidermis in a condition of exfoliation in 
finger-nail-sized lamellated flakes. Even in these extreme cases the 
tendency of the disease to avoid surfaces exposed to the light is dis- 
tinctly manifested. Unna 2 describes an anomalous feature of the dis- 
ease, in which the maculations occur in annular form with a clearing 
centre. Rarely, also, a very few irregularly distributed macules may 
be seen as the sole evidences of the existence of the parasite. Thus, a 
patient may exhibit a small-coin-sized patch on the surface of the chest, 
another on the shoulder, and possibly a third over the deltoid region 
of one arm. These are generally cases partially relieved of a more 
diffuse eruption. More commonly the slightest manifestation of the 
malady is an irregular, vertically arranged, somewhat narrow band of 
lesions immediately over the sternum, and visible beneath the hairs of 
that region in the adult male, or upon the intermammary sulcus of 
women. The face, hands, palms, soles, hairs, hair-follicles, and nails 
are usually exempt. 

Etiology. — The disease is produced by a vegetable mould, discov- 
ered in 1846 by Eichstedt, to which Robin gave the name Microsporon 
furfur. In capabilities for contagion it is far inferior to the vegetable 
parasites already described, and it illustrates well a point to which at- 
tention already has been directed, viz., that these fungi flourish only 
in soils suitable for their germination and fructification. Members of 
one family are said to communicate the disease occasionally, the one 
to the other ; and Lancereaux 3 reports that in this way he accidentally 
infected himself from scales collected for examination from a patient 
in hospital, and afterward unwittingly transmitted the affection to his 
wife. The disease occurs in both sexes, rarely before puberty and after 
middle life, and in persons of every social condition, irrespective of 
personal cleanliness. It is exceedingly common, more so, indeed, than 

1 E. O. Smith, N. Y. Med. Jour., 1896, lxiv., p. 583, reports a case in which the 
disease was limited to both soles; and Gottheil, N. Y. Med. Kec, 1899, lvi., p. 15, a 
case in which the left palm was involved. 

2 Vierteljahr., 1880, xii., p. 165. 

3 Traite d'Anatomie pathol., xi., p. 265. Paris, 1875. 



858 



PARASITIC AFFECTIONS. 



statistics are capable of demonstrating, inasmuch as hundreds who are 
annually annoyed by it never seek professional advice. In physical 
examinations made with a view to the enlistment of men for military 
service, as also of government pensioners, the disease is often recog- 
nized upon the persons of those who pay no attention to its pres- 
ence. Being concealed by the clothing and unproductive of much dis- 
comfort, many subjects of tinea versicolor endure its presence with 
complacency. 

By some it has been supposed that the fungus selects the chest of 
the phthisical as its habitat, a supposition doubtless based upon the 
fact that tuberculous men and women, more than all others, expose 
the chest to the view of medical men in order to permit of its auscul- 
tation and percussion. 

Pathology. — The Microsporon Furfur (Fig. 93) is readily recog- 
nized with the aid of the microscope, as it exists in luxurious profusion 
upon every affected surface. The scales may be scraped from the skin, 
and at once be examined, when innumerable clustered spores and short 
threads become visible ; the former highly refractive and resembling in 
their circular and oval contours droplets of oil. Their aggregation in 
clusters is distinctive of this among the other forms of cryptogamic 
vegetation. They measure 0.0023 to 0.0084 mm., while the hyphse 
vary in diameter from 0.0015 to 0.0038 mm. (Duhring). Among the 
latter, sporophores are distinguishable, with contained conidia and 



Fig. 93. 




Microsporon furfur. (After Kaposi.) 



terminal elements emerging at one extremity or the other of the spore- 
case. Both elements are stained more readily by eosin and methyl- 
violet than those of the tricophyton or of favus. By the use of special 



TINEA VERSICOLOR. 859 

media, Matzenauer l and Gaston and Nicolau 2 have succeeded in culti- 
vating the fungus. 

One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter- 
esting mould. It never by any possibility invades the hairs or the 
hair-follicles, though it may be seen flourishing at the orifice of a fol- 
licular duct, and even beneath a vigorous pilary growth upon the chest 
of a male subject. It avoids light and air ; and singularly refuses to 
encroach even upon certain covered portions of the body, preferring, in 
its extreme development, to linger unobtrusively at the neck near the 
verge of the collar. 

Diagnosis. — In this disease, as in all parasitic affections of vege- 
table origin, the microscope may be required to decide the diagnosis 
in any case in which doubt arises. In its simpler manifestations the 
recognition of the affection is readily assured. The location of the 
eruption, its irregular reticulations, its characteristic yellowish or fawn- 
tinted shades of color due to the nature of the fungus, and the exfolia- 
tion of the epidermis which it excites by its superficial penetration of 
the outer layer of the stratum corneum, producing thus a mealy, branny, 
flaky, or roll-like exuvium, are all significant. None of the chloas- 
mata due to pigment-changes in the skin, however much they may 
resemble tinea versicolor in color, share with it this peculiarity of des- 
quamation. Chloasma may involve, moreover, the face ; tinea versi- 
color almost never. Vitiligo occurs upon the scalp ; tinea versicolor 
very rarely. The macular syphiloderm may be mistaken for the dis- 
ease under consideration, but, when developed to such an extent as to 
rival tinea versicolor in its diffuseness, the syphiloderm will creep out 
over the face, the hands, and the feet, and will be accompanied by 
adenopathy, alopecia, mucous patches, palatine hyperemia, or will fur- 
nish evidence of a polymorphic tendency. Often, indeed, with such 
an eruption, the survival of the initial sclerosis will at once betray the 
nature of the disease. These are important considerations, since in the 
mere matter of subjective sensation, color, shape, and size of lesion 
there may be marked resemblance between the two. Patients exhibit- 
ing the lesions of tinea versicolor may suffer from syphilis ; and many 
having the former disease, in consequence of a suspicious exposure 
believe they are infected with lues, and yet indeed are not. These 
incidents serve to illustrate the importance of making an accurate diag- 
nosis in every case of cutaneous disease. 

The most common error committed in this connection, however, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor and either the liver itself or the color-changes which 
disease of that viscus is capable of producing in the skin. The exist- 
ence of " liver-colored " spots in the skin is, hence, erroneously attrib- 
uted to hepatic disease. Few patients consult physicians for relief of 
this disorder who have not a belief in the internal origin of the disease. 

Treatment. — A single method of relieving tinea versicolor is recom- 
mended for the simple reason that it invariably is successful. It 

1 Archiv, 1901, lvi., 1G3. 

2 Bull, de la Soc. frany. de Dermat, 1902. 



860 PARASITIC AFFECTIONS. 

requires merely vigorous and intelligent cooperation on the part of 
the patient. A hot bath is taken, if possible, for three nights in suc- 
cession, and when the surface is well macerated in hot water the 
affected skin is scrubbed either with the cheap yellow soap of the 
shops, or with sapo viridis in substance or in tincture. When the 
disease is extensively developed this process is aided by friction with 
a flesh-brush or with a coarse towel. The skin is then washed clean 
with a surplus of hot water, and dried, after which the affected patch 
is first moistened with vinegar and water, or dilute acetic acid, and 
afterward well sponged with a solution of sodium hyposulphite, 1 
drachm (4.) to the ounce (30.) being usually sufficient. As a rule, 
the greater part of the eruption is removed with the third application. 
If there be recrudescence in isolated patches, as is often the case, or 
outlying areas which have withstood the parasiticide employed, they 
should subsequently be attacked with a solution of mercuric chloride, 
1 to 2 grains (0.066-0.133) to the ounce (30.). Other measures, how- 
ever, are popular with physicians, and among them may be named the 
topical use of boric, carbolic, or sulphurous acid ; tincture of iodine ; 
sulphur in bath, ointment, or lotion ; calomel in ointment ; the alkalies 
in bath or lotion ; potassium sulphide in bath ; chrysarobin, pyrogallol, 
tar, Wilkinson's salve, and the other parasiticides employed in the 
treatment of ringworm of the body. Leven l secures an exfoliation 
of the skin and a removal of the disease by embrocation of oil of tur- 
pentine four or five nights in succession. Whatever parasiticide be em- 
ployed, after treatment the inner clothing should not be worn until it 
has been immersed in boiling water. 

The following formula is also recommended : 

R Hydrarg. chlorid. corros., £j ; 1 33 

M. 
[Anderson.] 

Prognosis. — The disease can readily be relieved by simple treatment. 
Relapses often occur, and require to be radically treated. Untreated, 
the disease may continue for years without the slightest impairment of 
the general health. It is probable that when untreated the parasite 
undergoes spontaneous exfoliation in advanced years, a period when 
presumably the fungus fails to find in the epidermis the nutriment upon 
which it thrives. 

ERYTHRASMA. 2 

(Gr. tpvdpog, red.) 

Burckhardt first described this disorder in 1869, but it received its 
name in 1862 from von Barensprung. It has since been studied and 
described by Balzer, Riehl, Koebner, Pick, and others. 

1 Monatshefte, 1901, xxxii., p. 197. 

2 Kecent literature: Payne, Some Rare Diseases of the Skin, London, 1899 (re- 
view of literature) ; Balzer, La Pratique Dermatologique, ii., p. 540 (bibliography). 



Hydrarg. chlorid. corros., 


Rj; 


i 


Saponis viridis, 


|ij; 


60 


Spts. vin. rectif., 


3iv; 


120 


01. lavandul., 


f3j; 


4 



ERYTHBASMA. 



861 



Symptoms. — The disease first appears in punctiform to palm-sized, 
roundish, definitely circumscribed maculations, presenting a sharp con- 
trast in color with that of the adjacent integument. This hue varies 
somewhat according to the location of the patches. The younger lesions 
may exhibit a vivid redness over the entire macules or over their borders 
only. The older lesions exhibit a yellowish or a brownish tinge. These 
colors are compounds of ordinary erythematous redness and yellowish 
or brownish discoloration of the horny layer of the epidermis. 

The macules are circular or rosette-shaped, or they display very irreg- 
ular outlines. They are not raised to any extent above the general 
level of the skin, though the finger passed over the surface can recognize 
a slight elevation of the border, due to hyperemia, and subsequent 
moderate, flour-like furfuraceous desquamation, most conspicuous also 
at the periphery. Vesiculation and papulation do not occur. The 
colors recognized in different patches may be light reddish-brown, pale 
reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered where apposed surfaces 
of the skin come in contact, as in the axilla?, the groins, the cleft of 
the anus, and the regions where the scrotum touches the thigh ; it 
occurs, however, in typical expression on both sides of the chest. The 
eruption spreads slowly and in serpiginous outline until the affected 



Fig. 94. 




Microsporon minutissimum, from patches of erythrasma. 

surfaces are completely invaded. It is much more chronic in its course 
than the other dermato-mycoses, lasting for months and years without 
apparent change. 

Etiology. — Erythrasma is produced by the growth, in the superficial 
layers of the epidermis, of the fungus described below. Men are much 
more often affected than women ; children not at all. The youngest 
patient whose case is recorded was sixteen years old ; the oldest, 
fifty-five. 



862 PARASITIC AFFECTIONS. 

Pathology. — The fungus termed Microsporon Mintjtissimum 
(Fig. 94\ to which the disease is attributed, is chiefly remarkable for the 
extraordinary delicacy and fineness of its threads and its very minute 
spores. The threads are either simple cylindrical bodies of variable 
size, or they may exhibit partition-septa ; they may divide dichotomously, 
and may terminate in hooked or knobbed expansions. They are inex- 
tricably interwoven when occurring in large masses. The largest 
transverse diameter is 0.6 [i • in length the mycelium presents the 
greatest variation. Bacteria and heaps of zoogloea are visible among 
the scales. The granules are piled into irregular heaps, according to 
Burckhardt, and they give a dusty appearance to the epidermal cells 
on which they lie ; often the outline of these granules is indistinct. 
According to the same observer, the breadth of the hyphse is Y2V0 mm * > 
and the length from y 1 ^ to -^-J-q- mm. 

Pasquale de Michele 1 discovered the leptothrix in cases of supposed 
erythrasma ; and this is but another of the proofs that in all diseases 
of this class, as in so-called " eczema marginatum," there are few in- 
stances in which a single mould-fungus develops on the body-surface. 
The entire flora dermatologica of Unna may be effective in more cases 
than is commonly believed. 

Diagnosis. — From all ordinary chloasmata and pigment-macules the 
spots of erythrasma are distinguishable by the ease with which the 
superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater difficulty ; 
but the latter occurs in different situations by preference, its patches are 
more vividly red, and the parasite, under the microscope, presents 
distinctive features. 

The Treatment is that of tinea versicolor ; and the Prognosis is 
favorable, subject to the disappointments arising from frequent relapses. 

LA PERLECHE. 

Under this title, Justin Lemaistre 2 describes a contagious disease 
observed by himself in more than three hundred children of Limoges. 
It is not rarely recognized in the skin-clinics of the Paris hospitals. 
The malady is characterized by dryness, smarting, cracking, and exco- 
riation of the lips, the epithelium of which becomes blanched, mace- 
rated, and readily detached. Hemorrhagic and painful fissures form 
in the direction of the commissural folds. Often plaques are visible, 
suggesting mucous patches. The disease lasts for from fifteen days to 
a month, with possible recurrence which may lead to a year's suffering. 

The disease is of parasitic origin, communicated by drinking from 
cups used by infected persons. Lemaistre attributes the disease to a 
streptococcus plicatilis which he has cultivated in Pasteur flasks. The 
microbes were originally found on the borders of epithelial cells of 
the lips of infected children. The parasite lives in the form of a 
micrococcus in stagnant water, wells, and springs. The disease is one 
of uncleanliness, and is readily prevented by appropriate hygiene. 

1 Annales, 1891, s. 3, ii., p. 776. . 

2 Le Progres med., 1884. For later literature see Jacquet, La Pratique Dermatolo- 
gique, in., p. 839 (bibliography) ; and Bureau et Fortineau, Presse med., 1902. 



FINTA. 863 

MYRINGOMYCOSIS. 

(Otomycosis.) 

The spores of aspergillus (niger, flavus, fumigatus), being conveyed 
to the external ear, occasionally develop there, especially if they come 
in contact with fatty substances introduced for purposes of medication. 
There can then be recognized in the canal whitish masses, covered 
with grayish-white, yellowish, greenish, brownish, or blackish spots. 
In the normal ear this vegetation cannot flourish ; its occupancy of 
the canal is conditioned on a maceration of the epidermis due to some 
antecedent inflammatory or other affection. 

Examination of the debris removed from the ear reveals the inter- 
laced hyphse of the vegetation with spores and occasional flower-like 
masses which constitute the sporangium of the fruit-capsule of the 
aspergillus, this last containing the receptaculum and radiating sterig- 
mata bearing the conidia. Diffuse inflammation, otorrhcea, and eczema 
of the part may result. There is usually some deafness, with a sensa- 
tion of ringing in the ears, and at times a thin serous discharge from 
the external auditory meatus. Lowenberg 1 recommends for the de- 
struction of the mould the injection of dilute alcohol into the canal and 
the subsequent insufflation of boric acid in powder. 



PINTA. 

(Mal de los Pintos, Mal Pintado, Pinto Cute, Cativi, Tinna, 
Quirica, Spotted Sickness, Spotted Disea.se of Central 
America, Ponnus Carateus. Fr., Caratke.) 

Pinta is an endemic dermato-mycosis, characterized by the develop- 
ment of pigmented patches upon the skin in different colors, uncon- 
nected with the general health of the patient. 

The disease occurs in tropical America, especially in Mexico, Cen- 
tral America, Venezuela, Colombia, Bolivia, Chili, Peru, and Brazil ; 
but it has been found also in North Africa, and, it is believed, also in 
Guiana. 2 

Symptoms. — Pinta begins at one or several points of the body- 
surface, whence it is distributed more or less generally by auto-infec- 
tion. The disease, by some authors, is said to be preceded by prodro- 
mata of chills, fever, anorexia, cephalalgia, vomiting, diarrhoea, and 
emesis, lasting for one week, the cutaneous symptoms developing about 
one month later. The occurrence of such a prodromal stage has, how- 
ever, been denied. 

The eruptive symptoms develop gradually. The hands, face, and 
other exposed parts usually are involved first. Large areas subse- 

1 Gaz. hebd. de Med. de Paris, 1880, 2me ser., xvii., p. 579. 

2 Bibliography : Scheube, Diseases of Warm Countries, with good illustration by- 
Edgar from Jour. Trop. Med., p. 531. Manson, Tropical Diseases, p. 632. Gomez, 
Du Carathes ou tache endemique des Cordilleres, Paris, 1879. Hirsch, Handbuch histo- 
geogr. Pathologie, 1883, 2d ed., ii., p. 263. Montoya and Florez, Annales, 1897, s. 3, 
viii., p. 464, 



864 PARASITIC AFFECTIONS. 

quently are formed by increase in the dimensions, and also by coales- 
cence of original macules, the spread of the disease being asymmetri- 
cal and peripheral. The spots may be characteristically yellowish, 
reddish, bluish, blackish, whitish, or gray, the hue at first being mono- 
chromatic ; later, as the disease spreads, the different colors named 
above may be exhibited side by side. The patches are well defined, and 
do not affect the palms and soles. On the scalp the hairs whiten 
and fall. 

The surface of the body, when extensively involved, presents an 
odd-looking, piebald appearance, due in part to epiphytic changes and 
in part to the development of vitiliginous patches in the skin. Itching 
is produced in various degrees, according to the extent and severity 
of the disorder. When the affection has lasted for some time, a dis- 
gusting odor is exhaled, and the surface exfoliates, an early furfuraceous 
desquamation being replaced later by scaling in large flakes. 

Two types are described : one superficial, represented by blackish 
and bluish patches ; and a deeper form, said to be more obstinate, with 
reddish and whitish patches, in which the deeper portions of the epi- 
dermis are involved. 

Though displayed for the most part asymmetrically, the patches 
may cover the entire surface of the body, and even invade the mucous 
membranes of the alimentary tract. When confluence occurs, large 
areas of the skin may be involved, displaying then the usual features 
of hyperkeratinization, with pityriasic, occasionally larger and coarser, 
scales, infiltration, occasional Assuring, and complete or partial color- 
change and loss of hair. In final evolution the symptoms are highly 
suggestive of other dermatoses, such as trichophytosis, favus, some of 
the forms of lupus, and erythematous eczema. There may be ulcer- 
ative complications. 

The disease may persist indefinitely if not relieved. It yields to 
proper parasinoidal treatment. Mild relapses occur. The general 
health is not involved. 

Etiology. — Pinta is a contagious disease, affecting persons of both 
sexes and all ages, save infants ; but is much more common among the 
filthy and the neglected than in others. * It is produced by the growth 
of a cryptogamous fungus in the superficial portions of the skin. 

Pathology. — When the scales scraped from the skin of a patient 
affected with pinta are moistened with liquor potassse and placed under 
a microscope, round or oval, blackish spores 8-12 fi in diameter, and 
highly refracting, short, dichotomous filaments of mycelium are dis- 
tinguishable. The effective parasite is of the aspergillus family, fine 
filaments giving rise to hyphse which terminate in clubs surrounding 
chaplets of spores. Sterigmata encircle the sporulating elements. 
The fungus is found chiefly in the superficial layers of the epiderm, 
but may also, in advanced cases, be recognized in the rete. Whether 
the differences in color be due to variations in the fungus or to pig- 
mentation of the spores and filaments, is not determined. 

Diagnosis. — The patches of chloasma, vitiligo, and lepra are dis- 
tinguished readily from those of pinta by considering that, in the two 
diseases first named, there are no surface-changes in the horny layer 



PLATE XXX] 



/ 




Dr. Hyde's Case of Mycetoma. 

(From a painting:.) 



MYCETOMA. 865 

of the epidermis, and in the second the existence of a systemic affec- 
tion is established readily. The absence of anaesthesia in the patches 
of pinta, the discovery of microsporon furfur in tinea versicolor, and 
of microsporon minutissimum in erythrasma, and the special charac- 
ters of the psoriasiform dermatoses, are all of significance. Care should 
be taken to exclude the symptoms of the prefungoid stage of mycosis 
fungoides. 

Treatment. — This is to be conducted by the aid of chrysarobin, 
sulphur, iodine, naphtol, and, if needed, by corrosive sublimate lotions. 
Cleanliness and strict observance of the requirements of hygiene are 
demanded especially in the class of patients who are affected most often 
by the disease. 

MYCETOMA. 

(Gr. [ivktjc, a fungus.) 

(Podelcoma, Madura Foot, Morbus Pedis Entophyticus, Ulcus 
Grave, Endemic Degeneration of the Bones of the Foot, 
Morbus Tuberculosus Pedis, Elephant Foot, Madura 
Disease, Fungus Foot of India, Fungus Disease of India, 
" Egg-foot." Ger., Madurafuss ; Inch, Perical, . Slipada ; 
Fr., Mycetome, Pied de Madure.) 

Mycetoma is a localized affection limited to the skin and adjacent 
parts, due to invasion of the tissues by vegetable parasites, and charac- 
terized by the production of an unshapely tumefaction of the invaded 
part, which becomes covered with nodules or tubercles for the most 
part permeated by fistulous sinuses. The disease not only affects the 
skin, but also the underlying structures to a variable extent. It long 
was thought to be a malady occurring only in India, but more lately has 
been recognized in China, Syria, parts of Africa, and in both ISorth 
and South America. 

The record of its first recognition on the American continent is 
embodied in the apparently unsupported statements of Euelle, 1 who 
reports that Collas observed one case at La Keunion, Grail and 
Grand-Mourrel each one case in Guiana, and Layet one in Chili and 
another in Valparaiso. McQuestin saw three cases affecting native 
Mexicans in the Civil Hospital of Hermosillo, and Kemper reported 
a case which for some years was thought to be the first occurring in 

1 Bibliography : Adami and Kirkpatrick, Trans. Assoc. Amer. Phys., 1895, x., 
p. 92. Arwine and Lamb, Amer. Jour. Med. Sci., 1899, cxviii., p. 293. Boyce, Hyg. 
Rundsch., 1894, iv., No. 12. Surveyor, Brit. Med. Jour., 1892, p. 575. Carter, Trea- 
tise on Mycetoma, or the Fungus Diseases of India, London, 1874. Dantec, Le, Arch, 
de med. Xaval, 1894, p. 447. Gemy and Vincent, Annales, 1896, p. 1253. Hatch, 
Keith, and Child e, Lancet, 1894, p. 1271. Hyde, J. N., and Senn, N., Jour. Cutan. 
Pis., 1896, xiy., p. 1. Kanthack, A. A., Lancet, 1892, i., p. 195, and ii., p. 169 ; Jour. 
Path, and Bact, Oct., 1892. Manson, Tropical Diseases, p. 614. Paltauf, Intern. Klin. 
Rundsch., 1894, No. 26. Pope and Lamb, N. Y. Med. Jour., 1896, lxiv., p. 368. 
Ruelle, Contribution a 1' etude de mycetoma, Bordeaux, 1893, p. 13 el seq. Scheube, 
Falcke, Cantlie, loc. cit., p. 552 (full bibliography). Shah, T. M., Med. Rep., Calcutta, 
1893, p. 225. Vincent, Annales de PInst. Past., 1894, p. 129. Wright, Trans. Assoc. 
Amer. Phys., 1898, xiii., p. 471, 
55 



866 PARASITIC AFFECTIONS. 

the United States, but a critical examination of the description of the 
acute symptoms presented by his patient raises doubt respecting the 
accuracy of the diagnosis. Parkes reported that he had operated suc- 
cessfully upon a patient suffering from mycetoma in the city of 
Chicago. The disease, however, had been contracted in India. 

The first case certainly known to have originated in North America 
in which no question exists as to the diagnosis was reported by Adami 
and Kirkpatrick. The subject was a French Canadian. Soon after 
the appearance of this report one of us, in connection with Senn and 
Bishop, published the record of an undoubted case of mycetoma occur- 
ring in a native of Iowa who had never been outside of his native State 
before visiting the city of Chicago. The lesions of the disease, as 
exhibited in the foot removed from this patient, are depicted on the 
accompanying plate. Since then Pope and Lamb, Wright, and Arwine 
and Lamb have published full reports of undoubted cases, with demon- 
stration of the fungus and its subsequent artificial cultivation. This 
record of five cases of Madura foot in North America includes the 
history of four men and of one woman. 

The disease was referred to first by Kampfer in 1712, but was differ- 
entiated clearly from elephantiasis first by Godfrey in 1843. It has 
been studied carefully since by Ballingall, Eyre, Carter, Kanthack, 
Bocarro, Surveyor, Gemy, and Vincent. 

Symptomatology. — There are three varieties of mycetoma classified 
loosely by the color of the morbid material contained in the discharge, 
viz., the black, the red, and the white, or ochroid ; the last named is 
the most common, the second the rarest, the black rather less frequently 
encountered than the white. Some doubt exists as to whether all are 
produced by one fungus, seeing that no intermediate forms between the 
varieties thus distinguished have been recognized. The part prin- 
cipally affected in most of the Indian and in the American cases is the 
foot, and this chiefly of persons walking barefoot ; but the hand, the 
shoulder, the thigh, the knee, the toe, the abdominal wall, the scrotum, 
and other regions have been attacked. Simultaneous involvement of 
different regions of the body has never been noted. As distinguished 
from the lesions of actinomycosis, it is noteworthy that the regions of 
the jaw and the neck usually are spared. 

In a typical case the sole of the foot is involved by progressive 
spread of the disease from the site of a trifling traumatism which often 
at first heals and is followed later by the development, near the site of 
the wound, of a rounded, firm, painless, small nut-sized subcutaneous 
button or nodule which increases slowly in volume and later is sur- 
rounded by similar lesions. In the course of five to ten weeks or 
more, the tumor softens and bursts, discharging a characteristic viscid 
semi-purulent, blood-streaked fluid which contains minute roundish 
(grayish, reddish, or blackish) particles, which have been compared 
to fish-roe. These may be agglomerated to pea-sized masses. At the 
site of each lesion a sinus penetrates deeply beneath and is said never 
to undergo spontaneous healing. The repetition of the process by the 
multiplication of nodules and fistulous tracts produces eventually the 
deformity characteristic of the disease. The progress of the malady is 



MYCETOMA 



86 



exceedingly chronic, as ten and many more years have been recorded 
not rarely as requisite for its complete evolution. 



Fig. 95. 




Osseous lesions in mycetoma. 



In fully developed cases, when the foot is involved, the organ is 
seen to be largely increased in volume, producing a bulging of the 
parts posterior to the digits over the dorsum above, and below over 
the plantar region, giving the sole a convex appearance. Over the 
tumid parts the skin is beset with numerous pea- to nut-sized iso- 
lated nodules, elevated to the extent of several millimetres above 
the general level, each pierced with a fistulous channel extending 
from without to the deeper structures. At times these fistulous tracts 
lead only to the soft parts and especially to muscular tissues ; at others 
the surface of the bone is reached and the osseous tissue is eroded bv 



868 PARASITIC AFFECTIONS. 

the growth of the parasite and the coccogenous infection which results 
from long exposure of the parts to the air. It is through these fistulous 
orifices that in different cases exit is given to a blackish fish-roe-like 
substance, or to a whitish material, or even- still more rarely, as indi- 
cated above, to a reddish substance. 

In place of nodules or papules, the skin may be the seat of pustules, 
of vesicles, of bullae, or even of abscesses. When but relatively small 
organs of the body are invaded, such as a finger or a toe, it becomes 
clear that the tumefaction is not due chiefly to a hypertrophy either 
of the integument or the bones. 

The discharge varies in different cases. In some it is almost 
wholly wanting : in others it is scanty : in yet others exceedingly pro- 
fuse and fetid. It is generally oily or syrupy in character. When 
blackish in hue, the contained granules have been likened to truffles or 
fish-roe ; when of paler hues, it resembles fish-spawn. 

The course of the disease is exceedingly chronic ; and while one or 
more nodules have been seen to heal, the mass of the disease persists 
until relief is obtained by artificial methods. 

Pain is usually not pronounced ; sensibility is maintained ; and the 
general health undisturbed for long periods of time. Death, when it 
ensues, results from long-continued drain upon the vitality of the 
patient. 

Etiology. — The disease is due to invasion of the tissues by a vege- 
table parasite which is either identical with the ray-fungus or a member 
of the same family. The precise class to which the fungus belongs 
has not been determined. 

It is probable that the parasite secures access to the skin by the 
medium of a traumatism, and the occurrence of a large majority of all 
cases on or near the foot, most often in men and among individuals 
who have been walking barefoot, lends support to this view. Further, 
the origin of a few cases has been traced to foot-lesions (bruising of 
the organ with a stone and consequent abscess : injury with a pitch- 
fork, a fall on the knee, etc.) ; while the relative freedom of persons 
who protect the feet while residing in the districts where the disease is 
common, is in evidence. The lower class of poor agriculturists, during 
the twentieth to the fiftieth year of life are most liable to the affection, 
while children and infants escape. The origin of the disease has not 
been traced to any peculiarities of soil. 

Pathology. — The effective parasite in Mycetoma has been termed 
variously actinomyces Madurse ; streptothrix Madurse (Vincent) ; oospora 
Indica (Kanthack) ; and discophyces Madurse (Nocard and Blanchard). 

In the white variety, tbe friable soft and rounded or kidney-shaped 
granules are seen under the microscope to be composed of colonies of 
a ray-fungus in the meshes of which can be recognized the products 
of an inflammatory process excited by the presence of the intruder, 
viz., closely packed leucocytes, new-formed vessels, walls infiltrated 
with proliferating cells, many or few giant-cells, and amorphous gran- 
ular masses. 

The fungus is seen to be composed of a central reticulum with fine 
interlacing mycelium surrounded by a closely set framework of radi- 



MYCETOMA. 869 

ating hyphse, many of these terminating in distinctly club-shaped knobs. 
The ovoid spores to be seen measure 1.5 by 2 jut. 

Sections of morbid tissue disclose the fact that the parasite exists 
in softened tissues as well in the neighborhood of the cysts and tunnels 
as in the latter. According to Kanthack, in the period of the early 
reactive inflammation, the fungus is surrounded merely by the results 
of cell-proliferation ; typical granulation-tissue, epithelioid cells, and 
new- vessel formation follow ; and lastly come the degenerative forms 
of the fungus, including the clubbing of the rays, loss of tinctorial 
qualities, vitreous changes, and the pigmentation of the mycelium. 

This last introduces to the vexed question of the origin of the 
different colors in the varieties of the disease known as the " white/' 
the " black," the " red," etc. In the " black " variety the grains are 
superficially mamelonnated, are firmer and more friable than the white ; 
they are not readily decolorized by chemical agents ; some exhibit no 
fungus, others show a series of moniliform tubes with radii less marked 
than in the white variety, though minute clubs have been found at the 
terminals. It is true that both white and black forms have been recog- 
nized as of simultaneous occurrence in one subject ; and transitional 
forms have also been found ; but the rarity of these cases, the differ- 
ence in the size of the filaments in well-marked instances of the two 
varieties, and the failure of most attempts to cultivate on artificial 
media the fungus found in the black variety, are to be given weight. 
The fungus of the white variety has been cultivated on infusions of 
hay and of straw, on meat broths, milk, potato, and other media 
(Vincent). 

The etiological relations of the fungus to the disease have been 
doubted by Cunningham, on the ground of the absence of the parasite 
in some cases, and its variant color and other characteristics in different 
cases, but the well nigh constant presence of the parasite and the 
striking character of the Madura foot argue against the theory that the 
fungus merely vegetates on a suitably prepared soil. 

The bones when denuded are found to be honeycombed with finely 
carved seams, depressions, furrows, and pits, leaving delicate spicula 
of osseous tissue projecting between the excavations wrought by the 
growth of the parasite. It is possible to find, as Adami suggested in 
the study of his case, intrusive organisms, the result of exposure for 
so long a period of time of the deeper tissues to the atmosphere. 

The relations of mycetoma to actinomycosis are still under discussion. 
The absence of all visceral involvement in mycetoma ; the failure of 
that affection to involve the tissues about the neck which are invaded 
frequently in actinomycosis, the exceeding rarity of the development 
of actinomycosis in the site of predilection of mycetoma, viz., the foot ; 
and, lastly, the persistence of the last-named disease under medicinal 
treatment which has altered practically the prognosis in actinomycosis, 
are considerations of importance in this connection. 

The fungus differs from that of actinomyces in that the former 
reacts indifferently to, while the rays of actinomyces are colored bril- 
liantly by acid fuchsin. 

Diagnosis. — The disease in all cases of long standing is readily 



870 PARASITIC AFFECTIONS. 

recognized by the characteristic deformity it produces, by the escape of 
fish-roe-like particles in the black variety, and in others by the dis- 
charge of the elements of the fungus, which can be determined by the 
microscope. The nodes or papules visible externally in all well-marked 
cases, each perforated with a sinus leading downward to the deeper 
structures, and the painlessness for the most part of the involved 
organ, are all characteristic. 

As distinguished from actinomycosis, it is well to remember that in 
mycetoma there is never involvement of the viscera ; the disease is 
exceedingly chronic j all systemic symptoms are absent ; and the 
aifection is common in countries where actinomycosis is practically 
unknown. 

Treatment. — The disease is radically treated by surgical ablation 
of the affected organ or by erasion of tissue. Even after evolution of 
the disease for years recovery in cases so treated is satisfactory. 

In amputation of an affected part or organ, it is needful to recall 
the fact that the bones and other tissues may be invaded at some dis- 
tance from the obvious lesion of the disease apparent in the skin. 

Treatment by the iodide of potassium, efficient in many cases of 
actinomycosis, has been found valueless in mycetoma. 



ACTINOMYCOSIS OF THE SKIN. 

(Gr. clktIq, and ^vktjq^ mushroom.) 

(" Lumpy-jaw." Ger., Aktinomykose ; Fi\, Actinomycose.) 

In 1877 Ponfick proved that the disease, first recognized by Bollin- 
ger in the jaws of cattle was the same as that which Israel in 1877 
had observed in man. 1 Hartz, judging largely from its morpho- 
logical characters, described the parasite as the ray-fungus. Maiocchi 
was first to describe the disease as it- involves the skin. It is to the 
cutaneous manifestations of the disorder that attention here is directed 
specially. 

Symptoms. — In actinomycosis, the parasite commonly gains access 
to the economy by the mouth, especially by the avenue of a carious 
tooth ; and the skin, when implicated, as a rule is involved secondarily. 
Such skin-lesions displayed are more often about the face and neck, 
more particularly the lateral surfaces of the neck beneath the jaw, 
where deep subcutaneous nodes, tumors, or swellings, often firm- to the 
touch, livid in hue, thinning at one or at several points after involve- 
ment of the integument, finally burst, forming fistulous tracts and 
giving exit to a serosanguineous or bloody and purulent fluid, con- 

1 Illustrations: Neumann's Atlas, Plate XIII. ; Morris, Lancet, June 6, 1896; Prin- 
gle, Med.-Chir. Trans., 1895 ; Kopp's Atlas, Plate LXXV. ; Corlett— cut appearing in 
Stel wagon's treatise, p. 1050 ; Illich, Wien., 1892 ; Darier et Gautier, Annales, 1891, p. 449 ; 
Ponfick, Treat. Berlin, 1882; Israel, Treat. Berlin, 1884; Skerritt, Amer. Jour. Med. 
Sci., 1887 ; Poncet et Berard, Trait., Paris, 1898 ; Bodamer, Med. News, 1889 ; Crook- 
shank, Lancet, 1898, p. 11 ; Legrain, Annales, 1891, s. 3, ii., p. 772 ; Baracz, Wien. med. 
Presse, 1889, xxx., p. 6; Ljunggren, Nord. med. Arch., 1895; Kopfstein, Wien. med. 
Eundschau, 1901, p. 21 ; MacCullum, Centralbl. o. Bakliv., 1902, xxxi. ; Howard, Jour. 
Med. Besch., 1903, ix., p. 301. 



ACTINOMYCOSIS OF THE SKIN. 871 

taming friable, yellowish or grayish masses in which the fungus may be 
recognized. The orifices of the sinus or sinuses after such discharge 
are usually beset with cutaneous and subcutaneous nodules and uneven 
lumps, some softened, others firm and indurated, usually reddish or 
purplish in hue, tender, painful, and often accompanied by pains else- 
where, particularly in mastication, in deglutition, and in certain move- 
ments of the head on the neck. The outlying skin becomes infil- 
trated, tumid, empurpled, and boggy. Rarely papillomatous growths 
develop. 

The onset of the disease is insidious, and though occasionally rapid 
in its career, its evolution may extend over months and even years. 
The nearer to complete development of the disease the more rapid, 
as a rule, is the oncoming of its symptoms. In exceptional cases the 
malady attacks the fingers, the hands, and other parts of the body. 
Rarely, secondary actinomycosis of the lymphatic glands occurs. 
Pringle reported a case in which large areas on the back, lumbar 
region, and hip were affected secondarily after involvement of deeper 
organs. 1 Lymphatic metastasis is, however, rare, due, as is believed, 
to the large size of the fungus-granules as compared with the lumen of 
the lymphatic vessels. Subjective symptoms may be insignificant or 
be related to the pain and stiffness of the neck concurrent with the sub- 
cutaneous abscesses. 

Etiology. — As in mycetoma, more men than women are attacked 
as a result of special exposure ; a few of the affected have been occupied 
with cattle and horses ; others having carious teeth may have been 
infected by accidents of contact or in the operations of dentistry. The 
subjects are usually young adults, though we have treated a male patient 
over sixty years of age. Cases are on record of transmission from man 
to man, from animals to man, and by traumatism when inanimate 
objects were the media by which the fungus was introduced. The 
affection is communicable by inoculation. Murphy had a case of this 
disease in the person of a woman whose dog had died with a large 
swelling under the jaw. In most instances there have been submax- 
illary lesions and carious teeth. The general dispersion of the ray- 
fungi in the atmosphere, water, and upon the soil is held to explain in 
large measure the occurrence of the disease in man. Beards of barley, 
bits of wood and stone, vegetable fragments, etc., have been found in 
actinomycotic lesions. 

Pathology. — Actinomycosis is produced by invasion of the human 
body by pathogenic micro-organisms, not by specific infection with a 
single ray-fungus as was believed originally. In the most commonly 
recognized type of the disease, the fungus is found in the yellowish or 
grayish masses discharged in clumps from the fistulous tracts and found 
also in sections of morbid tissue. Often there are seen fine interlacing 
threads or filaments radiating from a common centre, some considerably 
projected above their fellows, many with a bulbous expansion at the 
tip (" clubs "). These are believed to be the fructifying elements and 
the source of the spores often found free in the vicinity of the granules. 

1 Med.-Chir. Trans., 1895, lxxviii., p. 21. 



872 PARASITIC AFFECTIONS. 

The threads are slender, sinuous, often with dichotomous branches, and 
have an external sheath and protoplasmic medulla. 

Seeing that there is a series of different micro-organisms capable of 
producing the several recognized varieties of actinomycosis, and that by 
the methods of bacteriology no definite distinction can be made between 
true actinomycosis and pseudo-actinomycosis, it is now recognized merely 
that there are two broad divisions of the genus actinomyces, the acid- 
resisting and the non-acid-resisting (or acid-bleaching), typical tubercu- 
losis being produced by one member of the former group, and typical 
actinomycosis by a large number of organisms in the latter group (How- 
ard). The growth of the parasite in the tissues results in the forma- 
tion of granulation-tissue which may undergo purulent disintegration ; 
and there may be extension of the process by hematogenous metamor- 
phosis, rarely by secondary actinomycosis of the lymphatic glands and 
vessels, by dissemination by phagocytes of mycelial fragments, and 
lastly by secondary mixed infections with the pyogenic micro-organisms. 

Diagnosis. — All supraclavicular and submaxillary lesions consti- 
tuted of dark-reddish tumors or swellings, subcutaneous in origin, 
should carefully be differentiated from actinomycosis. Scrofuloderma 
is to be recognized by the general condition of the patient (actinomy- 
cosis may occur in vigorous young adults) ; by the absence of pro- 
nounced gumma and lymphoma (" gomme scrofuleuse ") ; and by failure 
of recognition of the parasite, which is not easy of detection. The 
occupation of the subject of the disease (as a farrier, stable-boy, or 
drover) may furnish a clue to the origin of some cases. Care should 
always be taken, in making a diagnosis, to exclude cases of swellings 
discharging pus, practically limited to the skin immediately over the 
lower jaw, with sinuses leading to the bone beneath, in which the dis- 
order is exclusively due to a carious fang of one of the lower central or 
canine teeth. All these may be relieved by extraction of the offending 
tooth. 

The Treatment has been until recently by surgical procedures, era- 
sion, antisepsis by mercuric chloride, LugoPs solution, boric acid, and 
dressings with antiseptic gauze. Gautier has employed with success 
an electro-chemical method of treatment, by the use of platinum 
needles and injections of a 10 per cent, potassium iodide solution. 
Two needles are inserted, one connected with each pole of the battery, 
and a current of fifty milliamperes is passed; a few drops of the 
iodine solution are injected during the flow of the electricity, the 
patient being anaesthetized. Before attempting surgical measures 
potassium iodide given internally should be tried, since it has proved 
successful in many cases. Pringle's patient improved under the 
iodide, though never able to take the remedy in large doses. He 
eventually died from amyloid disease. Morris reported a case which 
under the influence of the iodide lost its characteristics and the fungus 
gradually disappeared. Other cases are reported in which recovery 
followed administration of the medicament. 

Prognosis. — It was held until lately that the prognosis was favor- 
able only in case of thorough and prompt removal of all diseased tissue. 
In other cases a fatal result was anticipated. 



PLATE XXXII. 




Blastomycosis. 

(From a photograph.) 



BLASTOMYCOSIS. 873 

Schlange, however, at the Congress of German Surgeons held in 
1890, called attention to the fact that of nearly two hundred patients 
under his observation (over one-half traced since 1886), forty were com- 
pletely cured for more than two years ; and in eighty the disease re- 
mained limited to the head and neck. After thirteen years of involve- 
ment one patient at the date of the report was alive. All extensive 
operations for relief of the malady are now abandoned. Potassium 
iodide is effective in some cases, and is worthy of a trial in all. Even 
actinomycosis of the lungs and viscera is susceptible of spontaneous 
recovery. Cases apparently hopeless have recovered in five and six 
years. Intestinal complications are grave. 

BLASTOMYCOSIS. 1 

(Blastomycetic Dermatitis, Saccharomycosis Hominis, Derma- 
titis Blastomycotica. Ger.j Hefekmykose.) 

Blastomycosis is a chronic, inflammatory, infectious disease, charac- 
terized by the appearance upon the skin of a small papule or papulo- 
pustule, which becomes crusted and extends peripherally to form a 
sharply outlined, elevated, verrucous patch situated upon a pus-infil- 
trated base and presenting a characteristic, abruptly sloping border in 
which are seen minute, deeply seated abscesses. Blastomycetes are 
found in the sero-purulent contents of the abscesses, from which both 
budding and mycelial forms of organism have been obtained in pure 
culture. 

The invasion of the bodies of animals by blastomycetes had been 
studied before the disorder was recognized in the human family. In 
1894 Busse published an account of a fatal case of pyaemia, with 
subcutaneous abscesses and cutaneous manifestations, in which the 
pathogenic agent was a yeast. A few months earlier, Gilchrist had 
demonstrated before the American Dermatological Association micro- 

1 For a more detailed review of the clinical, histological, and bacteriological features 
of cutaneous blastomycosis, with 16 clinical and 25 histological and bacteriological 
illustrations, a brief summary of 13 of our own cases, and bibliography, see report by one 
of us, Jour. Amer. Med. Assoc, 1902, i., p. 1486. For a full consideration of experi- 
mental work, and animal inoculations with blastomycetes, see Buschke's complete 
monograph, Bibliotheca Medica, D. II. H. 10, 1902 (illustrations and bibliography). 
For valuable contributions and full references to researches on blastomycetes, protozoa, 
cancer bodies, and cell inclusions, see the Second Annual Report of the Cancer Com- 
mittee to the Surgical Department of Harvard Medical School, Jour. Med. Besch., 
1902, vii., No. 3. 

Recent cases: Gilchrist, a case in a negro, with illustrations, review, and bibliog- 
raphy, Brit. Med. Jour., 1902, ii., p. 1321. Sheldon, report of a case, Jour. Amer. 
Med.' Assoc, 1902, ii., p. 1356. F. H. Montgomery, a case of cutaneous blastomycosis 
followed by systemic tuberculosis, Jour. Cutan. Dis., 1903, xxi., p. 19. Ormsby and 
Miller, a systemic case with multiple cutaneous and subcutaneous lesions, a full report 
with illustrations. Sequeira, report of a case, Brit. Jour. Derm., 1903, xv., p. 121. 
Evans, "A Case of Cutaneous Blastomycosis from Accidental Inoculation," Jour. Amer. 
Med. Assoc, 1903, p. 1772. Pusev, two cases presented to the Chicago Derm. Soc, 
Jour. Cutan. Dis., 1903, xxi., p. 223. Fischkin, report of a case, 111. Med. Jour., 1903, 
v., p. 472. Gilchrist, three cases, with four clinical illustrations, and abstract of McCar- 
rison's report of a case which occurred in a native of Northern India. Jour. Cutan. 
Dis., 1904, xxii., p. 107. The records of nine cases now under observation in Chicago 
have not been published. 



874 PARASITIC AFFECTIONS. 

scopic sections containing budding organisms from a lesion which 
Duhring considered a scrofuloderma. Later communications from 
Busse and Buschke and from Gilchrist and Stokes have been followed 
by reports from a number of observers, including Curtis, Wells, 
Hessler, Anthony, Bray ton, Stelwagon, Dyer, Shepherd, and ourselves. 
The records of nearly fifty cases, published or unpublished, in which 
the nature of the disease has been demonstrated satisfactorily, are now 
available. The following description is based chiefly on the clinical, 
pathological, and bacteriological study of 19 cases, 17 of which have 
been under more or less constant observation by us for periods ranging 
from four months to six years, 12 of them having been under our care 
for a year or longer. Of these we have studied the histopathology in 
18 and obtained cultures in 16 cases. In addition, we have had the 
privilege of studying clinically 6 patients, histological sections from 10 
cases, and organisms from 5 cases reported or to be reported by other 
observers. 

Symptoms. — The disorder begins as a papule or papulo-pustule, 
which soon becomes covered with a crust. The lesion slowly enlarges 
peripherally in the form of an indolent, flat, wart-like or crusted 
papule. In the majority of all cases the lesions had existed a number 
of months and had attained a diameter of an inch or more before the 
patient applied for treatment. We have had the opportunity once of 
watching a lesion grow from the initial small papule. 

In lesions that have attained the diameter of half an inch or more, 
the following characteristics are apparent : The patch is elevated from 
one-eighth to three-eighths of an inch above the surrounding skin ; 
the surface is covered by irregular papilliform elevations, separated by 
clefts or fissures of varying depths, giving it a verrucous or cauliflower 
appearance. In the younger and near the border of the older lesions, 
especially of those which have been kept clean, the papillary projec- 
tions are fine and the surface is fairly firm, dry, and wart-like. Portions 
of larger areas, and especially of those which have been untreated, are 
covered by more or less bulky and adherent crusts, on removal of 
which the papillary elevations are seen to be larger, lobulated, even 
subdivided, and bathed with a sero-purulent secretion. Some of these 
crust-covered projections are very vascular, a slight touch causing 
them to bleed. In exceptional instances the area under a crust may 
present the appearance of an ordinary unhealthy ulcer, with exuberant 
granulations. In older lesions the papillomatous surface may be 
replaced in part with a thick, elevated, scar-like formation, pinkish- 
white in color, irregular and often corded, but having a smooth, 
shining surface. The base of the active lesion is always soft and 
more or less infiltrated with sero-pus, which, on slight pressure, oozes 
between the papular elevations. 

The border of the area is one of the most characteristic features. 
It slopes more or less abruptly from the elevated roughened surface to 
the normal skin, from which it is sharply defined. It is smooth, of a 
dark red or purplish-red color, is from one-eighth to three-eighths of 
an inch wide, and on close inspection is seen to be set with a large 
number of minute abscesses. Many of these abscesses are so small 



PLATE XXXIII. 









„_'____.. 





Clinical Types of Cutaneous Blastomycosis. 



BLASTOMYCOSIS. 875 

that they are not visible to the naked eye, but can be recognized with 
a lens magnifying from two to six diameters. Others vary in size up 
to that of a pinhead. Some are superficial, but many, especially the 
smaller ones, are deep-seated. When carefully punctured with a fine 
needle, these abscesses give exit to a small amount of a thick, glairy 
mucus or muco-pus, the purulent character of the secretion increasing 
with the size of the pustule. From the smallest abscesses the amount 
of mucus expressed is sometimes so scanty that it can only be seen 
with the aid of a lens, yet it is from these minute abscesses that the 
organisms are best obtained in pure culture. Abscesses of the same 
sort occur also in other parts of the growth, and not infrequently on 
the thick, scar-like tissue described above, but in characteristic develop- 
ment they are best seen on the sloping border. The number of 
abscesses varies in different cases and in the same case at different 
times, depending somewhat upon the activity of the process. 

The course of the disease is irregular but essentially chronic. 
Usually a number of months elapse before the original patch attains a 
diameter of an inch or more. It may remain indolent for months or 
even years, with irregular periods of activity and progress, but, as a 
rule, extension of the area is slow and continuous. In about half the 
cases the original patch of the disease has been followed in the course 
of weeks or months by one or more new lesions in adjacent or other 
regions of the body. In some instances the clinical evidence of auto- 
infection has been very strong. The majority of the areas sooner or 
later attain the size of a silver dollar or of the palm, and some of them 
become much larger. As the disease ends at the periphery, heal- 
ing frequently occurs in the central portion of the growth. In this 
manner large areas (in Anthony and Herzog's patient the greater 
portion of the thigh and leg) may be involved in various stages of the 
process. Healing sometimes occurs spontaneously. Whether sponta- 
neously or as the result of treatment, the first indication of healing is 
found in the gradual flattening and disappearance of the papillary 
projections, partly by absorption, partly by desiccation and exfolia- 
tion. At the same time the amount of secretion from the underlying 
base diminishes, and the whole patch assumes more of an ordinary 
verrucous appearance. In many instances the papilliform surface is 
replaced temporarily by the hypertrophic scar-like tissue described 
above, which in turn gradually disappears and gives place to the char- 
acteristic cicatrix, which eventually becomes soft, supple, non-attached, 
pinkish-white, and, on the whole, very inconspicuous, though always 
sharply outlined from the surrounding skin. As a rule, the resulting 
deformity is very slight. In some instances where destructive agents 
or scraping operations have been employed, the disappearance of the 
characteristic lesion is followed by an ordinary indolent ulcer, which 
heals with a thickened and somewhat deforming scar. 

During the healing process, though the miliary abscesses decrease 
in number, careful search will reveal them even in scar-tissue that has 
become quite thin and soft. It is consequently not uncommon to see 
areas that apparently have healed, become more or less covered again 
with active points or areas of disease. A single patch may thus present 



876 PARASITIC AFFECTIONS. 

nearly all stages of the disorder, showing at the same time several of 
the following features : the advancing border ; new-forming lesions on 
old scars ; verrucous or cauliflower lesions in various stages of develop- 
ment or disappearance ; a base in places dry and firm and in others 
soft and infiltrated with muco-pus ; a scar-tissue, in part thick and 
irregular and in part smooth, soft, supple, and non-attached to the 
deeper tissues. 

The regions involved are usually those most accessible to local 
infection, the disease occurring with greatest frequency on the face, 
hands, wrists, or forearms ; but no portion of the body is exempt. 
Involvement of the mucous membranes proper has not been reported. 
The eyelids are a frequent seat of the disease, but the conjunctiva 
escapes, though ectropion resulting from destruction of the lid causes 
conjunctivitis and keratitis, due to exposure. Adenopathy has been 
noted in systemic cases only, though pus infection of lesions may be 
followed by a transitory involvement of adjacent glands. 

The subjective sensations of the disease vary greatly. As a rule 
pain is slight or absent except in areas which are acutely inflamed as 
a result of secondary infection. 

The majority of patients have been in good general health, though 
some have suffered from other systemic disorders, which evidently 
bore no definite relation to the blastomycosis. Of the entire number, 
one patient only died of generalized tuberculosis. In three cases death 
occurred from systemic infection with blastomycetes, the organisms 
being demonstrated at the autopsy in the viscera, and in two cases in 
the blood. One of the three patients l remained in vigorous health for 
seven years after the appearance of cutaneous lesions and then rapidly 
developed grave constitutional symptoms. In the other two, systemic 
infection evidently preceded the evolution of cutaneous lesions. 2 In 
the Busse-Buschke case the systemic symptoms were those of pysemia, 
with subcutaneous abscesses and necrosis of bone. In the other two 
cases the symptoms were those of pulmonary tuberculosis, with 
irregular exacerbations of temperature, arthritic pains, and the forma- 
tion of disseminated subcutaneous nodes which suggested those of 
erythema multiforme, but on rupture gave exit to a thin, sanious, 
muco-purulent matter, and in some instances were transformed into 
typical cutaneous lesions. We have under observation a case of 
systemic blastomycosis in which the symptoms correspond closely to 
those of the two last described above, and another patient with long- 
continued and extensive cutaneous lesions (persistent because of 
neglected treatment) who shows symptoms of systemic infection. 

Etiology. — A local infection with the fungus peculiar to each case 
is the sole recognized cause of the disease. In one instance a slight 
wound of the finger incurred at the autopsy of a case of systemic 
blastomycosis was followed in one week by the appearance at the site 
of the injury of a pustule which refused to heal and later developed 

1 Montgomery- Walker case. 

2 Dr. Cleary recently presented to the Chicago Pathological Society a case which 
the autopsy showed to be one of systemic blastomycosis, in which there were no 
cutaneous lesions. 



PLATE XXXIV. 




■■m 



Ms 



Vertical Section from a Typical Lesion. 

a, hyperplasia of rete ; b, abscesses in epithelium ; c, infiltration of cutis, x 55. 



WWK:.:3^W^v^F^'W, 




Budding Organism in 
Tissue, x 1200. 




Hanging Drop, x 1200. 



BLASTOMYCOSIS OF THE SKIN. 

(From photo-micrograph.) 



BLASTOMYCOSIS. 877 

into a typical cutaneous lesion in which pudding organisms were dem- 
onstrated repeatedly. The infectious character of the disorder is 
demonstrated further by successful inoculation of animals. In several 
instances there has been a history of trauma preceding infection. What 
other conditions favor the origin and development of the process have 
not been determined. Why certain yeasts and mould fungi are patho- 
genic, while others are innocuous, how common in nature the patho- 
genic varieties are, and how they differ from the ordinary varieties, are 
unsolved problems. 

No relation has been discovered betwen the disease and the sex, 
occupation, nativity, or habits of the individual affected. The fact 
that the majority of cases occur in men is due probably to their more 
frequent exposure to infection. About half the cases have occurred 
after the age of forty, the twentieth year being the earliest in which 
the disorder has appeared. No definite relations between blastomycosis 
and other local or systemic disease has been demonstrated. The possi- 
bility of blastomycetic infection being secondary to lesions of other 
disorders or to trauma is admitted ; it is equally possible for the lesions 
of blastomycosis to be infected secondarily with tuberculosis or other 
disease. 

Pathology. — Histologically the lesions resemble those of verrucous 
tuberculosis or of superficial epithelioma, yet differ from both. The 
surface, on which are seen irregular masses of debris consisting of pus, 
blood- and epithelial cells, and various bacteria, is marked by irregular 
papilliform projections, between which are corresponding depressions. 
The horny layer may be destroyed or it may extend in thickened 
masses between distorted papilla?. 

The rete is everywhere the seat of excessive hyperplasia, producing 
branching down-growths varying greatly in size and shape. Polymor- 
phonuclear leucocytes are scattered throughout the epithelium, both 
between and wdthin the cells, and occur often in small collections which 
form the beginning of miliary abscesses. These abscesses are charac- 
teristic of the process, and are found in all parts of the hyperplastic 
epithelium, in places breaking through to the surface. They contain 
leucocytes, nuclear fragments, detached epithelial cells, epithelial detritus, 
red blood-corpuscles, the organisms peculiar to the disease, and in many 
cases giant-cells. The epithelial cells surrounding the abscesses are 
flattened, but appear to take no active part in the process. The epithe- 
lium is separated from the corium in most places by a distinct layer of 
columnar cells, in which mitoses are seen occasionally. The rete-cells 
in general are large and appear swollen, the prickles being very con- 
spicuous and the intercellular spaces increased. Premature cornification, 
more or less complete, occurs in scattered individual cells, in groups of 
cells, and occasionally in isolated epithelial whorls. Single giant-cells, 
surrounded by a few leucocytes, are sometimes seen in the epithelium at 
some distance from the corium. 

The corium is the seat of subacute, chronic, and occasionally of 
acute inflammatory changes. Miliary abscesses occur, especially in 
acute lesions. The infiltration consists chiefly of leucocytes, endothelial 
cells, and plasma-cells, and is sometimes very dense. The number of 



878 PARASITIC AFFECTIONS. 

mast-cells and giant-cells varies in different cases. Tubercle-like 
nodules are found in some instances. In several cases sections showed 
numerous hyalin bodies which varied greatly in size, and occurred 
chiefly in plasma-, giant-, and new connective-tissue cells. 

The appendages of the skin apparently play but a passive part in 
the process. 

The blastomycetes are found in miliary abscesses, between the epithe- 
lial cells and in the corium, and are always surrounded by more or 
less evidence of inflammation. They are rarely found within the cells. 
The giant-cells, however, usually contain one or more of the parasites. 
The number present in the tissue varies greatly. In some cases a dozen 
or more can be seen in a single field of the microscope, while in others 
they are found with difficulty. They occur usually in pairs of unequal 
size, but also singly and in groups. They are readily seen in sections 
stained with hematoxylin and eosin or other common stains, but methy- 
lene-blue is best for showing the different parts of the organism. The 
fungus is easily demonstrated by placing fresh or hardened sections, or 
pus, in a strong solution of potassium hydroxide, or in equal parts of 
liquor potassae and glycerin ; the organisms then appear as doubly con- 
toured, highly refractive bodies. 

When well stained, the parasite is seen to be a round, oval, or 
slightly irregular body, having a well-defined, double-contoured, homo- 
geneous capsule, and a finely or coarsely granular protoplasm, which is 
separated from the capsule by a clear space of varying width. The 
capsule resists the prolonged action of strong alkalies and acids. The 
protoplasm often contains a clear vacuole, which varies greatly in size 
in different bodies. Mature organisms have a diameter of from 7 to 20 
[i, though smaller and larger forms are seen occasionally. 

Budding forms are seen in all stages of development ; the capsules 
and clear space are pushed out apparently by the protoplasm to form 
oval buds, which grow to about one-half the size of the mother-cell 
before separating from the latter. Organisms in pairs of unequal size 
are more common than budding forms. 

Mycelium has not been demonstrated in tissue or in the contents of 
the abscesses. In two cases organisms in the tissues were filled with 
small globular bodies which reacted to stains like spores, but no further 
development of these bodies could be seen. 1 

In a systemic case, Ormsby excised a small-bean-sized subcu- 
taneous node, in which the epidermis was normal and the corium but 
slightly involved, the process being manifested chiefly in the subcuta- 
neous tissue. The zones of infiltration were for the most part fairly 
well defined about dilated blood-vessels. The infiltration consisted of 
large numbers of the organism, also leucocytes, erythrocytes, connec- 
tive-tissue, plasma-, mast-, and giant-cells in varying numbers. In 
places there was a suggestion of tubercle formation, in that the organ- 
isms, leucocytes, and red-blood cells were found chiefly in the centre 
of the node and surrounded by giant-, connective-tissue, and plasma- 

1 In a single case we found in the larger abscesses a few pod-like bodies, and frag- 
ments of a thick mycelium containing what appeared to be spores. 



BLASTOMYCOSIS. 879 

cells. In this and other systemic cases the organisms were very 
numerous and larger than those found in most of the cutaneous cases. 

The organism is obtained easily in pure culture from the minute 
deep-seated abscesses in the borders of the cutaneous lesions. Cultures 
taken from the larger abscesses and from teased tissue are contami- 
nated often with pus-cocci or other bacteria. The blastomycetes have 
been obtained repeatedly, however, in pure culture from pus-abscesses 
of considerable size, showing that the organisms are in themselves pus- 
producing. In cultural features the organisms from different cases 
have varied considerably, and it is possible that they will have to be 
classed in distinct botanic groups. On the other hand, individual 
organisms have been shown to vary greatly with the media employed 
and with other circumstances of culture, and the different types seen 
may be various stages of development of a single variety of fungus. 
The organisms grow rapidly on most ordinary media, and though by 
varying the media and other circumstances of growth a given organ- 
ism can be made to assume a variety of appearances, in most instances 
the type is that of a mould fungus, showing on agar or glucose agar a 
white, fluffy growth with aerial hyphse, and on glycerin agar a pasty 
growth with numerous folds and depressions. 

Under the microscope, cultures show budding organisms and myce- 
lium, that may be fine, homogeneous and branching, or coarser, more 
or less segmented, with or without lateral conidia. The mycelium may 
contain few or many highly refractive bodies, varying in size, which 
probably are spores. Mingled with the mycelium of older cultures 
are round, oval or irregular, double-contoured bodies, varying greatly 
in size and more or less filled with highly refractive, globular bodies. 
These globular bodies, like those seen in the coarser mycelium, behave 
in every way toward reagents like spores, but in no case have they 
been observed to develop into mature organisms. 1 Young colonies and 
cultures on glucose agar are made up of fine mycelium, with or with- 
out the presence of budding organisms. Older cultures and those on 
glycerine agar show much coarser mycelium and a preponderance of 
the circular spore-containing bodies. A bit of old culture made up 
entirely of these round bodies, placed in a hanging drop of bouillon, 
develops in two or three days an abundant fine mycelium, in which the 
spore-like bodies are disseminated. 

Though in tissues and in the abscesses the organism develops by 
budding only, fresh cultures from the abscesses show fine mycelium 
more frequently than budding forms. Animals inoculated with cult- 
ures composed of mycelium have developed abscesses from which bud- 
ding forms only were obtained. 

Inoculation-tests have been largely unsuccessful, but in several in- 
stances subcutaneous injection of pure cultures of the blastomycetes has 
resulted in the production of a local abscess, or of an inflammatory 
granulation-tissue, from which the fungus could be recovered. By 
inoculating the skin of animals with pure cultures of blastomycetes, 
Buschke succeeded in producing tumors which resembled closely the 

1 It is known that under certain conditions blastomycetes may develop by 
sporulation. 



880 PARASITIC AFFECTIONS. 

lesions of cutaneous blastomycosis in man. The organisms in several 
cases have been inoculated in animals with the production of tubercular- 
like nodules, or other inflammatory areas, in the lungs, kidneys, and 
other organs, from which the fungus has been recovered and cultivated. 

Diagnosis. — Though many of the cutaneous lesions of blastomycosis 
resemble verrucous tuberculosis so closely that a definite diagnosis can 
be established only after a microscopic examination of the tissue or of 
the contents of minute abscesses, lesions showing the typical border 
set with abscesses described above are so characteristic and are present 
so frequently that a positive clinical diagnosis is possible in most cases. 

The readiest means of confirming the diagnosis is to place the con- 
tents of one or more of the abscesses, or a bit of teased tissue, between 
a slide and cover-glass with a drop of a 20 or 30 per cent, solution of 
potassium hydrate. If distinct budding organisms are found, which 
resist the action of the alkali after the tissue and pus-cells have largely 
disintegrated (a change requiring from ten minutes to one hour), the 
diagnosis is practically established, but should be verified further by 
obtaining cultures of the organism and by histological examination of 
the tissue. 

Other disorders to be excluded by a consideration of their char- 
acteristic features are lupus vulgaris and other tuberculoses of the skin, 
the rare vegetating forms of syphilis, and protozoan infection, which, 
it is now believed, may be a variant of blastomycosis. 

Treatment. — Complete excision of the diseased areas has been prac- 
tised successfully in several cases, no recurrence having been reported. 
Curetting, employed in a number of instances, has not prevented a 
return of the disease. 

Large doses of potassium iodide, first employed by Bevan with one 
of our patients, arrests the progress of the disease and produces a 
marked improvement in the cutaneous lesions. From two to five hun- 
dred grains a day have been required in some patients before any effect 
on the morbid growth was produced. In three of our cases and in 
several reported by others the disease disappeared under this treat- 
ment. In the majority of patients, however, treated with large doses 
of potassium iodide, healing takes place rapidly over the greater portion 
of the area involved, but small patches remain, usually of the verrucous 
border, for indefinite periods ; and on the discontinuance of the potas- 
sium iodide the disease reappears with as great activity as before. In 
three of our patients who improved rapidly under the treatment up to 
a given point, the few remaining verrucous areas and abscesses disap- 
peared after a few exposures to the #-rays. Pusey in two cases, and 
Fischkin in one, have had good results from the combined use of potas- 
sium iodide and the #-rays. 

For most lesions, cleansing and antiseptic lotions or dry dressings 
can be used with advantage. 

Prognosis. — Complete excision where practised has terminated the 
disease. Under the iodine therapy, the condition improves so decidedly 
that with the aid of the arrays, or other local treatment, the disease 
should be eradicated completely. Recurrences, however, are common, 
even after the last clinical evidence except scars has been removed. 



DISEASES DUE TO ANIMAL PARASITES. 881 

We have under observation one patient with recurrent disease in which 
the combined use of the iodide and the arrays has failed to arrest the 
progress of the disease, and two other patients who are in a serious 
state from what appears to be systemic infection with blastomycetes. 
Finally, four ! systemic cases have proved fatal. 

Protozoic and coccidioidal infections of the skin have been reported 
by Wernicke, Kixford and Gilchrist,* Posadas, D. W. Montgomery, 3 
and Ophiils and Moffitt, in which the cutaneous manifestations, both 
clinically and histologically, resemble very closely those of cutaneous 
blastomycosis. In the general symptoms, in the formation of sub- 
cutaneous abscesses, in the fatal termination, and in the larger size and 
greater number of organisms in the lesions, these cases correspond 
closely with those of systemic blastomycosis, with which they un- 
doubtedly are allied closely if not identical. In cases of protozoan 
infection the organism develops by endogenous spore-formation and 
never by budding ; w T hiie in blastomycosis the only method of develop- 
ment of the organism in tissue is by budding. Though in at least two 
cases of the latter disease the organisms have contained what un- 
doubtedly were endogenous spores, the development of these spores 
into mature bodies could not be demonstrated. The cultures obtained 
from cases of protozoan infection differ slightly from those obtained 
repeatedly in blastomycosis. It is possible that the difference between 
the organisms in blastomycosis and in protozoic disease may be due to 
the influence of climate, all reported cases of protozoic disease having 
originated in warm countries. 

Refractory Subcutaneous Abscesses caused by a Sporo- 
thrix are reported in two cases by Schenck, 4 and Hektoen and Per- 
kins. 5 In both cases infection occurred on the index finger, and 
produced subcutaneous nodules and abscesses along the lymphatics of 
the arm. 

DISEASES DUE TO ANIMAL PARASITES. 

The human skin may be attacked by animal parasites which (a) 
habitually exist upon or within the integument, securing their nutri- 
ment in these situations ; (6) exist upon the clothing, furniture, or other 
articles of environment of the body, attacking the latter only when in 
search of food : (c) are brought accidentally into contact with the human 
body and attack it when irritated or alarmed without seeking nutriment ; 
or (d) infest the vascular channels or viscera of the body and involve 
the skin only when approaching the surface as an accident of the human 
invasion. 

Some parasites are sexually mature ; others only in the larval con- 

1 Including Dr. Cleary's case, in which there were no cutaneous lesions. 

2 Johns Hopkins Hospital Keports, i., 1896 (a full report of two cases and of the 
organisms, with illustrations). 

• s Brit. Jour. Derm., 1900, xii., p. 343 (bibliography), and Jour. Cutan. Dis., 1903, 
xxi., p. 5 (a new case). 

4 Johns Hopkins Hosp. Bull., Dec, 1898. 

5 Jour. Exper. Med., 1900, vol. v., No. 1. 

56 



882 PARASITIC AFFECTIONS. 

dition. Few of the entire list confine their attacks to the human body, 
the most afflicting other animals as well as man. 



SCABIES. 

(Lat. scabere, to scratch.) 

(" The Itch." F/\, Gale ; Ger. 9 Keatze.) 

Scabies is a contagious cutaneous affection in which multiform lesions 
(papules, vesicles, pustules, excoriations, crusts) occur upon the axillary 
folds, the hands (especially the interdigital spaces), the wrists, the ab- 
domen, the upper thighs, and in infants often also the face and feet, 
characterized by intense pruritus with nocturnal aggravation, and due 
to the presence of acarus scabiei. 

Symptoms. — Scabies is a disease of polymorphic symptoms, which 
may be viewed as an artificial eczema or dermatitis, produced by the 
invasion of the itch-mite (Fig. 96). The objective symptoms differ 
according to the extent to which the skin is primarily invaded by the 
parasite, or is secondarily injured by traumatism and severe scratching 
of its surface. 

Prominent among the objective symptoms is the cuniculus, or acarian 
furrow, an elongated gallery excavated in the epidermis by the female 
acarus soon after her impregnation by the male. The male does not 
enter the skin, but is lodged beneath the crusts or other exuviae which 
gather upon its surface. This cuniculus, or furrow, is a whitish or a 
yellowish, slightly arciform, linear lesion, with regular parallel borders 
covered with dots or specks of blackish aspect, representing faeces of 
the mite. The furrow (Fig. 97) terminates at the upper extremity by 
a vesicle, pustule, or exfoliation of the surface at the site of an infun- 
dibuliform depression ; and at the deeper extremity by a whitish and 
yellowish, shining and salient point, representing always the acarus. 
This is the most characteristic symptom of scabies. 

The "head" of the gallery, where the parasite first entered the skin, 
is usually whitish, and is more elevated than the " tail," where the 
acarus rests after laying its dozen or more of eggs. At times the entire 
cuniculus forms an elevated ridge, rather than a thread-like depression, 
with white dots along its summit. When the roof of the vesicle at 
" the head " is torn off by scratching the effect is to produce a reddened 
spot at its site, surrounded by a whitish moat running around the 
entrance of the gallery. 

When the burrow exists it can be recognized most perfectly in the 
interdigital spaces and on the skin of the penis as a tangential line, 
running from a vesicle, papule, or pustule to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellowish 
or blackish thread, the color being more pronounced in comparison 
with a fresh-colored and washed skin, and less marked in contrast with 
a soiled surface ; being, in a soiled and subsequently washed integu- 
ment, most conspicuous in proportion as the small puncta have served 
to entrap particles of dirt. The cuniculus may be curved, angular, 



DISEASES DUE TO ANIMAL PARASITES. 



883 



or tortuous ; and occasionally may be seen well-nigh completely cov- 
ered by a bulla, pustule, or vesicle extending its entire length. In 
these cases, however, the female always penetrates beyond the periph- 
eral wall of such lesion, working her gallery beyond it and more 
deeply, lest she be lifted by the exudation out of reach of the succulent 
rete where she feeds. 

Fig. 96. 




Female acarus fecundated (ventral surface). An ovum arrived at maturity is visible within the 

body. (After Kaposi.) 



Hebra points to the fact that between two parallels, one drawn 
through the nipples and another at a short distance above the knees, 
on the anterior face of the body, can be recognized the greater part of 
the eruptive lesions in every case of scabies. 

The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 
in both sexes. As a matter of accident, it may appear, though rarely, 
in individuals of high social station. It is much more common in 
Scotland, Austria, Prussia, Sweden, Norway, France, and the Orient, 
than in America. During the late Civil War it prevailed with rela- 
tive frequency among the masses of Americans associated in regiments 



884 



PARASITIC AFFECTIONS. 



Fig. 97. 



with foreigners who had been but a short time in the country ; and 
steadily decreased after that time. But few cases until lately were 

seen annually in the public 
clinics of our large cities, 
though here and there, 
chiefly among newly arrived 
immigrants, isolated groups 
of cases of the disease were 
discovered. The influx of 
immigrants to the United 
States, however, in the last 
few years, has brought the 
disease again into promi- 
nence by reason of its greatly 
increased frequency. 

In consequence of the 
irritation produced by the 
parasite and the trauma- 
tisms by scratching, the 
region invaded may exhibit 
all the symptoms of acute 
and chronic dermatitis in- 
cluding vesicles, pustules, 
wheals, small papules, hy- 
peremia of the skin upon 
which these rest, crusts 
formed by dried serum, pus, 
and blood, excoriations, fis- 
sures, and, in cases of long 
standing, pigmentation of 
the skin where the disease 
has existed. These lesions 
may coexist, several appear- 
ing at the same time upon 
the skin of an affected indi- 
vidual ; small vesicles and 
pustules, with perhaps a few 
short cuniculi visible upon 
their summits ; excoriations ; 
larger and longer cuniculi 
interspersed between inflam- 
matory papules ; a tumid 
skin, evidently the seat 
of a mild grade of derma- 
titis ; and crusts here and 
there, beneath which male 
and young acari are en- 
of a typical eruption in 




Acarian furrow, from the lumbar region. The female 
acarus is visible at the terminal extremity of the furrow 
with ventral surface exposed, and containing a mature 
ovum; two ova, next her, bave been laid during the 
day ; the third exhibits traces of the embryo ; the twelfth 
exhibits a mature larva (a) ; twelve empty shells are also 
seen ; between these the feces are represented by black 
points. (After Kaposi.) 



-such is the composite picture 



sconced 
scabies. 

It will be remembered that the acarus family find nutriment, shelter, 



SCABIES. 885 

and all they require on the person of the individual whose skin they 
inhabit, and there is no inducement for them to colonize at the instant 
of the first opportunity offered. The transfer of a male acarus alone, 
from one person to another, would not insure a generation of the young j 
and the unimpregnated female could not alone do more. As for the im- 
pregnated female, Hebra, on several occasions, failed to induce scabies 
when one such female only was transferred intentionally to a sound 
skin and was seen to penetrate it. Lastly, the eggs alone would not 
suffice, for they have to be nicely planted within the epidermis in 
order to be hatched safely to maturity. In brief, only the more inti- 
mate contacts of the bed at night, and the application of nails charged 
with acari of both sexes, especially the young, are to be regarded as 
most effective for the transmission of the disease. This fact explains 
why nearly seven men are found to be affected with scabies to one 
woman. Women, as a rule, are more inclined to sleep alone, or with 
those only to whom they have family ties ; while laborers, boys, appren- 
tices, and persons of that class, including those who are strangers to 
each other, at times occupy the same beds, especially in large cities, 
where they are often huddled together at night like swine. 

The female acarus may be recognized always at the terminal extrem- 
ity of her gallery, for it is now known that she does not in her lifetime 
leave it for any purpose, as was at one time taught. The intruder here 
shows as a minute, whitish, clearly defined dot, presenting a contrast in 
this particular with the blackish feces in the gallery behind, and may 
in a good light, by a person of some dexterity and fair eyesight, be 
extracted on the point of a cambric needle from her lodging-point. It 
is important to know that this parasite may be recognized by the 
unaided human eye. Its characteristic tortoise-like body exhibits most 
of its anatomical peculiarities under a glass enlarging the figure but 
one hundred diameters. 

The regions affected by the eruption are the sides and roots of the 
fingers and toes ; the flexor aspects of the wrist-joints ; the feet (and 
especially in women, the delicate skin of the feet near the instep, 
partly dorsal, partly plantar in situation) ; the palms (especially of 
women and children) and the dorsal surfaces of the hands ; the but- 
tocks (more particularly in those who are seated in the trades and occu- 
pations of life) ; the extensor faces of the joints ; the belly ; the penis 
and scrotum in men ; the anterior folds of the axillae ; the nipples and 
breasts of women ; the elbows and knees, rather than the popliteal 
space and bend of the elbow ; and the anal region. Scabies, prurigo, 
and pruritus are alike in this, that in each the face and posterior aspect 
of the body display the fewest of any lesions visible. In general, por- 
tions of the body subjected to constant pressure by the clothing, as, for 
example, the regions pressed by the corset of the woman and the waist- 
band of the trousers in man, are sites of predilection. In other cases 
the disease is encountered in the axillae, the groins, and, as a matter of 
rare exception, over the entire surface of the body. 

The itching of scabies is occasionally severe, and has, in fact, con- 
ferred upon the disease its familiar English title, "the itch." This 
sensation is usually worse at night, when the parasite is rendered active 



886 PARASITIC AFFECTIONS. 

by the heat of the body in bed, retained by the bed-clothing. It differs 
somewhat in different cases, being at times the cause of but little com- 
plaint. There is nothing characteristic, however, in the occurrence of 
this symptom, as equally severe pruritus accompanies eczema uncon- 
nected with parasites. 

The itching which results from the epidermic tunnelling in progress 
is often noticeably more severe than would be suggested by the moder- 
ate number of skin-lesions visible. When these lesions (puncta, vesi- 
cles, pustules, blebs, papules, resulting crusts, furrows, excoriations, 
etc.) are found upon the hands the itching becomes so great that the 
infested person scratches also the accessible parts of the skin, where 
there were originally no acari, such as the inner side of the thighs, the 
lower belly, etc., as Hebra suggests, simply because they are " handy." 
Hence it is that the picture comes to resemble that of all pruritic and 
scratched skins. 

Several artificial forms of this polymorphic affection are noted occa- 
sionally. In infants the face may be invaded after contact with the 
breast of the mother or the buttocks after contact with the flexor 
aspect of the nurse's arm. Large vesicles, and even rupioid bullae, 
may result from irritation of the tender skin of children. Again, 
in subjects predisposed to eczema for any reason the invasion of the 
parasite in one region of the body, possibly a region of preference, may 
originate an eczema in another locality whither the parasite has not 
wandered. In other cases the most aggravated forms of eruption are 
seen, usually in persons of filthy habits who have long suffered from 
the malady. Thus, extensive epidermal callosities form, filled with 
debris of dead parasites unable to find nutriment longer in the corni- 
fied rete ; or extensive greenish and blackish crusts cover colonies of 
acari which survive beneath them for generations of their race. The 
nails in such extreme cases may be involved. The so-called Scabies 
Norvegica, or "Norwegian itch," belongs to this class. Hessler 1 
reported a case in which the entire surface of the body was covered with 
large, thick scales, which were shed freely and were riddled with acarian 
furrows. By counting the number of parasites in a scale of a given 
size he calculated that the man had upon his person at one time not 
less than 2,000,000 mites and 7,000,000 eggs. 

As a rule, the disease does not advance to severe grades. The 
parasites having gained lodgement in the skin produce characteristic 
symptoms of the disease in the average of cases, and, though un- 
recognized and persisting for weeks, are the sources of so much 
annoyance that treatment of some sort is instituted which is apt to 
restrict extension of the malady, certainly in America, within mod- 
erate limits. Usually after lodgement is effected a week or a fortnight 
elapses before the first characteristic furrow is formed, though the 
pruritus is of earlier occurrence. The extension of the disease by the 
maturing and ravages of young acari requires a few weeks more, so 
that in the course of from two to three months the evolution of the 
malady may be considered complete. In the course of about three 
months more the disease, unchecked, may become generalized. 

1 Med. News, May 13, 1893. 



SCABIES. 887 

Even the animal parasites elect the soil upon which they thrive, and 
indeed, after such election, thrive well or ill according to the conditions 
present. This is not only exemplified in the matter of individual sus- 
ceptibility, but in the conditions of health of an affected person. Thus, 
in puerperal and typhoid fevers and other grave states of systemic dis- 
turbance the parasites perish in the skin and the eruption disappears ; 
classical symptoms may recur in convalescence if one or more acari have 
survived with sufficient vigor to reproduce their kind. 

Etiology. — The disease is produced only by the Acarus Scabiei 
or Sarcoptes Scabiei), and is thus contagious, the parasites being intro- 
duced upon the surface of one individual mediately or immediately 
from the skin of another infested man or an animal. All persons are 
supposed to be susceptible to the disease, but the difficulty of intention- 
ally transmitting it by contagion is greater than that of inducing the 
leech to fasten itself indiscriminately upon any given skin. The brief 
shaking of the hand or transient personal contacts of the daytime are 
in many cases insufficient for contagion. Few practitioners of medi- 
cine suffer after careful examination of a patient. When a patient 
affected with scabies is exhibited at the clinic he is minutely and with- 
out ill results examined by dozens of students. It is probable that 
the contacts of the night incidental to the occupation of the same bed, 
or the use of gloves and other articles of apparel containing parasites 
or their ova, are essential to transmission of the disease. The parasites 
capable of inducing scabies in the lower animals (horses, dogs, sheep, 
etc.) occasionally are transferred to the human subject and are then 
capable of inducing irritation in varying grades. These parasites, 
however, rarely beget a disorder of the grade and intensity follow- 
ing infestation with the human acarus. The parasites soon perish from 
failure to propagate. 

Pathology. — The pathology of the eruption induced by the parasite 
is that of the various phases of exudation. The differences between 
scabies and all other eruptions of similar type depend, in the case of 
the former, upon the peculiarities of the exciting cause of the disease. 
In the description of this, the acarus scabiei, aid has been derived from 
the chapter devoted to this subject by Kaposi. 

The female acarus (Fig. 96), visible as a yellowish- white dot at the 
cul-de-sac of her subcutaneous gallery and removed thence on the point 
of a fine needle, is visible to the naked eye, but is best examined under 
the microscope. The body is oval, with a short projecting head and a 
convex dorsum transversely corrugated, with short spinous processes 
projecting for the most part backward, a direction largely followed also 
by the eight long bristles which are most noticeable at the posterior 
extremity of the trunk. The posterior portion of the dorsum also 
exhibits a series of recurved, short, hook-like projections, arranged 
circle-wise, about the anovaginal orifice. 

The flat ventral surface exhibits eight short claws or legs, four ante- 
rior and four posterior. The former are set near the head, and are 
provided each with hairs and a long pedunculated sucker ; the latter 
are armed solely with long, straight bristles. All the eight legs have 
five articulations. The head is oval in shape, and is provided with 



888 PARASITIC AFFECTIONS. 

four pairs of mandibles and six palpi. There are two ventral outlets ; 
and a stomach, intestines, ovaries, muscles, and even mature ova can 
be recognized internally. 

The males are smaller than the females and fewer in number. They 
differ also in this, that the posterior extremities are provided with suck- 
ers and stalks, as are the anterior extremities of the female. Situated 
between the stalks and the median line is a horseshoe-shaped mass of 
chitin ensheathing a fork-shaped penis. They are said to die in the 
course of from six to eight days after copulation. The latter survive 
from twenty to sixty days. 

The female alone, as has already been said, penetrates the epidermis. 
This act she accomplishes by inserting the head first into the tissues of 
the skin, the body disappearing afterward, and depositing behind, in 
the course of her progression downward, one or two eggs daily until 
from twenty to fifty have been laid. The eggs are oval, their longi- 
tudinal axes placed transversely to the cuniculus. In the two or three 
eggs found nearest the female only a yellowish color can be distin- 
guished ; in the third to the fifth, traces of the embryo are recogniza- 
ble ; the sixth to the ninth contain larvae ; and in the oldest the head 
and front legs can be discerned. When mature the shell of the ovum 
is ruptured, usually between the third and sixth day, and the young 
acarus reaches the surface of the skin either by making exit at the 
original point of entry of the mother or by rupture of the roof of the 
burrow. It subsequently buries itself in the skin for a brief time while 
the process of casting its slough is completed. There are three of 
these periods of existence. Before the first period is accomplished the 
young acarus is provided with but two pairs of posterior extremities, 
two anal bristles, and ten dorsal spines. After the first period it is 
an octopod with four oval bristles and twelve dorsal spines. At the 
second period it gains two dorsal spines, and after the third it pos- 
sesses fourteen. The acarus survives but a few days when removed 
from the skin and immersed in liquids which protect it from the air, 
such as water, oil, etc. 

Transmission to man of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished ; but the colony 
under these circumstances rarely thrives. The same is true of the 
human acarus when transferred to the lower animals. 

Diagnosis. — The diagnosis of scabies must rest upon the recognition 
of its special features described above. There are no lesions peculiar 
to the disease save the cuniculi, or furrows, made by the parasites, and 
they, it will be remembered, do not appear until one or two weeks have 
elapsed after infestation. They may also be obliterated or be concealed 
by excoriations when the finger-nails plough them open, or by pustu- 
lation and subsequent crusting when the irritation induced is excessive. 
In every well-marked case, however, cuniculi can be discovered, if not 
on the fingers, wrists, or forearms, at least on the penis, the breast near 
the nipple, or upon some other covered portion of the body. With care 
and a little dexterity a fine cambric needle can then be forced into the 
furrow well down to and a little beyond its remote cul-de-sac, and the 
fons et origo malorum be thence extracted and placed under the ob- 
jective of the microscope. 



SCABIES. 889 

Next to the cimiculus and its inmate or inmates, the two most 
important diagnostic features of scabies are the polymorphism of the 
eruption and the sites of its most frequent occurrence. These sites 
may be described as the most important of the two. Few skilled 
diagnosticians would fail to entertain a suspicion of scabies in a case of 
supposed " eczema/ 7 existing upon the fingers, wrists, and penis only, 
or upon the breast of a mother, and the face and buttocks of her infant, 
or the arms of its nurse. 

At the same time it is a matter of great importance to remember 
that eczema is often attended with very severe itching ; that this sen- 
sation may be intensely aggravated after retiring to bed at night ; that 
eczema is often limited to the hand ; it is not rarely characterized by 
interdigital vesicles and pustules ; and is, indeed, in America very 
much the more frequently encountered of the two diseases. The popular 
conception of scabies holds to the belief that the disease is exceedingly 
common ; that every severe itching with a cutaneous exanthem is pro- 
duced by " insects " or " worms " in the skin, and that transient casual 
contacts are abundantly capable of transmitting the offending parasite. 
Many more cases of simple eczema are supposed to be scabies than the 
reverse. There are few villages in this country which cannot lay claim 
to an " itch/' often known by a name of local significance. Among 
these provincial titles may be counted the u prairie itch " of the West. 
These affections are, as a rule, forms of eczema quite unconnected with 
the existence of a parasite, and incurable generally by the parasiticides 
too often employed to " kill " the disease. In all such instances the 
absence of the characteristic features of scabies described above, the 
absence of a history of contagion, and the presence of that of an alter- 
nating relief and aggravation of the symptoms, will point to the char- 
acter of the malady. In the severe pruritic affections of the West and 
the Northwest of America, described in the chapter devoted to the 
several forms of pruritus, it is noticeable that the patients are often 
cleanly — those who are careful as to the hygiene of the body. Scabies 
is really a filth-disease, and is best recognized among the filthy classes. 
Of diagnostic importance is the relative rarity of scabies among other 
cutaneous affections, pruritus included, observed in the United States. 

The Statistical Committee of the American Dermatological Asso- 
ciation from July 1, 1877, to January 1, 1898, reported 318,500 cases 
of skin-diseases of all kinds occurring in the United States and 
Canada. Of this number, 11,560 were instances of scabies, a per- 
centage of 3.66 to the total number of affections tabulated. The influ- 
ence of temporary increase of population and the crowding together of 
persons in large centres, many of whom came from foreign countries, 
is well illustrated by the statistics of scabies. 

Treatment. — The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the former 
has induced. Ordinarily these two indications are fulfilled at the same 
time. The destruction of the parasite is usually followed by relief of 
the resulting cutaneous lesions ; and the skin, freed from the burrowing 
acari, is no longer tormented by the scratching, wdiich in extreme cases 
is not only irresistible, but is also an important element in the aggra- 



890 PARASITIC AFFECTIONS. 

vation of the lesions. In other cases, however, the resulting derma- 
titis persists after removal of the original cause of the disease, and 
it demands special attention. Care should always be had to avoid 
treating the delicate skin of the infant with the severer remedies effi- 
cacious upon the thicker integument of the adult. 

Sulphur, in all its forms and various combinations, has long held 
the highest esteem in the treatment of the disease. Other remedies, 
however, of acknowledged efficacy are employed with satisfactory 
results, most of them owing their usefulness to the strong odor they 
emit. Among these remedies may be named carbolic acid, petroleum, 
naphtol, the oils of cloves, cinnamon, rosemary, and mint ; tar, balsam 
of Peru, and balsam of tolu ; styrax, staphysagria, Vleminckx's solu- 
tion (heretofore described), and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, 1 to 2 
drachms (4.-8.) to the ounce (30.), thoroughly rubbed, first into the 
affected patches, especially between the individual fingers (or toes), 
about the wrists, over the palm and dorsum of the hand, into the axillse, 
about the nipples, penis, buttocks, or other invaded parts, and, finally, 
over the cutaneous surface in general, the head alone excepted. If 
no severe eczematous complications exist, the inunction is well preceded 
by a warm soap or a warm soft-soap-and-water bath ; but in the event 
of such complication the bath should be deferred as decidedly injurious 
in the inflamed condition of the skin. 

The first inunction is preferably performed at night, after which the 
patient retires to bed enveloped in woollen underclothing or wrapped in 
a blanket. It is neither wise nor necessary to induce sudation by these 
measures, for the skin is best retained in simply a greasy condition, 
unmacerated by sweat. In England it is customary to bathe on the 
ensuing morning, but it is preferable to defer the bath until the cure is 
complete, however disagreeable the condition of the integument may be 
to the sufferer. The sulphur-inunctions are thus repeated for three 
successive nights, a thorough warm water-and-soap bath being finally 
employed for the purpose of cleanliness. The clothing meantime 
should either be thoroughly disinfected with sulphur, be immersed in 
boiling water, or be subjected in a stove or furnace to a dry heat 
capable of destroying all acari and ova which may adhere to it. 

In France, the routine treatment of scabies is always preceded by a 
thorough friction for twenty minutes with soft soap, special attention 
being as usual directed to the invaded areas. This operation is at once 
followed by a bath in warm water, during which the surface is also 
thoroughly scrubbed for from thirty minutes to an hour. Lastly, the 
parasiticide is w T ell rubbed on for fifteen minutes, the patient is redressed 
in the underclothing (disinfected during the progress of the bathing), 
and the final cleansing of the skin with water is practised within 
twenty-four hours. 

When a resulting dermatitis demands attention, it is to be treated in 
accord with the general principles considered in the chapter devoted 
to that subject. In this case the dusting-powders, the oleatecl lime-water, 
and the zinc, diachylon, and even more stimulating ointments, may be 
employed with advantage. Generally, after a vigorous course of exter- 



SCABIES. 



891 



nal treatment with sulphur, the patient should be instructed to defer 
any further topical applications to the skin for a week or more, in order 
to test the efficacy of the method pursued. 

Sherwell 1 finds sulphur in powder as efficacious as in ointment and 
less disagreeable. He directs the patient, after a soap-and-water bath, 
to rub gently over the body half a teaspoonful of sulphur lotum, and to 
dust the same amount between the sheets of the bed occupied at night. 
The bath, the powdering of the body and bed, and a change of clothing 
are repeated every two or three days. In the average case one week 
of such treatment is sufficient. 

One of the following formulas may be substituted for the ordinary 
sulphur ointment : 



R Sulphur, flor., 3xij ; 

Potass, subcarb., 3yj ; 

Adipis, %i'x; 

Hardy's modification of Helmerich's ointment. 



R Styracis liq., 
Petrol ei, j 
01. olivse, j 
Balsam. Peru v., 
Spts. sapon. virid., 



R Potass, sulphuret., 
Sapon. alb., 
Ol. oliv., 
01. thym., 



R Sulphur, sublim., "I 
Balsam. Peruv., } 
Adipis, 



f3j; 

aa f ,$ss ; 

f^ijss 
f3v; 



3v; 

3xx; 

f3iv; 

oftt. XV 



aa 3ss 
3J 



48 

24 

270 


M. 


4 




aa 15 




10 

20 


M. 

Kaposi.] 


20 
80 
16 

1 


M. 

Jadelot. 


aa 21 


30 

[I 


M. 

)uhring.] 



For use especially in the scabies of children. 

Hebra's modification of Wilkinson's salve, Vleminckx's solution, 
and balsam of tolu are employed for the same purpose. 
Kaposi's naphtol formula is : 



R Naphtol., 
Sapon. virid., 
Cret. alb. pulv., 
Axung., 



15 parts ; 

50 parts ; 

10 parts ; 

100 parts. 



McCall Anderson much prefers, on account of its pleasant aroma : 



R Styracis liquid., 

Adipis, 
Melt and strain. 



f3j; 



M. 



or Schultze's modification of Pasta v's formula 



R Styracis liquid., 
Spts. rectiricat., 
Ol. oliv£e, 

Ft. liniment. 



fSJ; 


30 


f3ij; 


8 


f3j; 


4 



Jour. Cutan. Dis., 1899, p. 494. 



M. 



892 



PARASITIC AFFECTIONS. 



Prognosis.— Scabies is a curable disease, even after persistence for 
long periods of time. When, however, complications exist, or severe 
eczema continues after the efficient action of a parasticide, the patient 
may experience delay before attaining complete restoration to health. 



Fig. 



DEMODEX FOLLICULORUM. 

(Steatozoon, or Acarus Folliculorum. Fr., Acare des Fol- 
licules; Ger. y Haarsackmilbe.) 

This parasite was discovered in 1841 by Henle. It is a microscopic 
creature in the form of an elongated and jointed worm, 
with head separated from the thorax, and eight legs, 
four on each side, each leg with three articulations, and 
terminating in three small hooklets. The posterior ex- 
tremity of the body is a vermiform appendage, termi- 
nating in a conical point (Fig. 98). 

The demodex folliculorum is found long after birth 
upon the free surface of the integument, those parts of 
the skin particularly where the sebaceous glands are 
large, and on patients affected with acne or seborrhoea 
oleosa, as well as upon those free from all evidences of 
disease. It is encountered also in the substance of the 
comedo-plug, where at times from five to twenty may be 
discovered in a single follicle. A demodex, which is 
considered to be a variety of that discovered upon the 
skin of man, infests dogs, mice, and other lower animals ; 
and may in the latter be the source of disease charac- 
terized by furuncular lesions, abscess, and even fatal 
results. None of these parasites is, however, known to 
be transmissible to man. 

It has never been demonstrated to be an etiological 
factor in any disease of the skin, though De Amicis 1 
and Majocchi 2 report cases of pigmentation of the skin 
Dem iorum follicu " dll e apparently to this parasite. 



PULEX PENETRANS. 

(Rhyncoprion Penetrans, Sarcopsylla Westwood, Nigua, 
Chigoe, Jigger, Sand-flea. Ft., Puce sable; Ger., 
Sandfloh.) 

The Sand-flea is a minute, brownish-red, egg-shaped parasite 
which penetrates the skin of man and of the lower animals, including 
rats and mice. It is encountered chiefly in tropical countries, but is 
said to exist in northern latitudes, even in some of the Southern States 

1 Giorn. ital. delle Malattie Veneree, e della Pelle, 1898, fascic iii., p. 205 ; also, Brit. 
Jour. Derm., 1899, p. 42. 2 Ibid. 



PULEX PENETRANS. 893 

of the United States. Only fecundated females attack the skin, in 
man usually about the toes or near the nails, entrance being effected 
with scarcely painful pricking sensations. In the course of from five 
to ten days a painful oedema with pustulation follows, occasionally ac- 
companied by lymphangitis or severer symptoms in the form of gan- 
grenous abscesses. These sequels are said to result from distention of 
the ovary of the parasite, which may exceed fivefold the original dimen- 
sions of the insect. 

The Treatment of the disease is by extraction of the flea with the 
aid of a heated needle, whereby it is destroyed simultaneously. The 
resulting wound may be cauterized or dressed antiseptically. 

PULEX IRRITANS. 
(Flea. Fr. f Puce commune ; Ger., Gemeinee Floh.) 

The Flea which specially attacks man is a brownish-red insect 
having a laterally compressed body, an oral haustellum, serrated soft 
mandibles, a tongue sheathed in an inferior labium, and a pair of labial, 
four-jointed palpi. Each of the triple segments of the thorax bears a 
pair of five-jointed, double-clawed legs. The male is from 2 to 5 mm. 
in length and 1 to 2 mm. in breadth, the female being nearly twice that 
size. The female deposits her eggs in any fissure, crevice, fold of gar- 
ment, or furniture which may be accessible, from which the larvae are 
produced in a week. The nympha is enfolded in a cocoon, but only 
the mature insects prey upon man. According to Geber, the insect 
injects an irritating fluid into the skin at the moment of attack. The 
lesion it produces is a hemorrhagic punctum, followed by a transitory 
hyperemia and a hemorrhagic exudation which may persist for a few 
hours. 

The central punctum, or point, distinguishes the wound produced by 
the insect from macules of simple erythema ; but care should be taken 
when fever is present to exclude the symptomatic erythemata. The 
site of the wound may become an urticarial wheal. 

Mixed cases of flea-bites with wounds produced by bugs and lice are 
often seen in the lowest classes applying for relief to public charities ; 
and the deeply pigmented skins they exhibit, often with purpuric 
lesions distributed over the lower extremities, and commingled with 
syphilitic eruptions, are in the highest degree confusing. The prac- 
titioner should always be on his guard in pronouncing on these cases, 
especially if the purpuric blotches occur in the cachectic or in those suf- 
fering from other diseases than those of the skin. 

The fleas of the lower animals occasionally are transferred to the 
human body, but rarely thrive on such a host. 

The Treatment of flea-bites is by carbolized alkaline and tarry 
lotions. Stelwagon recommends the wearing of bags filled with gum- 
camphor or pyrethrum beneath the clothing. Sulphur has been employed 
similarly. 



894 PRBASITIC AFFECTIONS. 

DRACONTIASIS. 1 

(Gr., SpanovTta, serpents.) 

(Filaria Medinensis ; Guinea- worm Disease ; Dracunculus 
Medinensis ; Medina Worm ; Guinea Worm ; Filaria 
Dracunculus. Fr., Dragonneau, Yer du Kutegal; Ger., 
Peitschenwurm ; Medinawurm; Holland., Guineesche 
Draake.) 

The records of the guinea- worm disease extend to a remote antiquity. 
It is a disorder due to invasion of the body by a nematode parasite, 
the Medina worm, and occurs almost exclusively in tropical countries, 
more particularly along the West African Coast, in the Soudan, 
Egypt, and Abyssinia ; in Asia, especially in the countries bordering 
on the Persian Gulf, in British India and the Fiji Islands ; and in 
America particularly in Guiana, Brazil, and the Antilles. 

Symptoms. — The lesions due to invasion of the skin by the dra- 
cunculus Medinensis are observed first at the point where the worm is 
about to make exit, which point may be at a considerable distance from 
that where it entered, and the exit may be made after an interval of 
several weeks or months. This approach to the surface for the purpose 
of securing exit is accomplished only when the worm is quite mature, at 
which time it can be felt beneath the surface, suggesting the presence 
of a soft cord. After some local sensation of tension or of itching, 
a pea-sized to small-nut or even egg-sized vesico-papule forms, super- 
ficial or subdermic in situation, which, after accidental or intentional 
rupture, gives exit to a clear serous fluid in which the uncolored head 
of the worm may be recognized. If the fluid be turbid, it is believed 
that the young embryos have escaped from the uterus. The head, 
which is surrounded by a quantity of leucocytes, appears either at once 
or in the course of a brief time, producing slow and sinuous movements 
by alternate contractions and elongations. The entire worm and its 
young may then wholly be extruded in the course of a week or more ; 
or the head may be withdrawn and another swelling form at another 
part of the surface, the first meantime closing ; or, in unskilfully man- 
aged cases, the worm may be torn so that the head only is removed, 
and then a severe lymphangitis with inflammatory, suppurative, and 
even gangrenous symptoms may supervene, producing, in fact, the 
train of symptoms now well recognized in connection with septicaemia. 
In some cases, however, the body may be discharged later than the 
head, after the mechanical separation of the latter, without serious con- 
sequences. The escape of embryos into the adjacent tissue is regarded 
also as a grave complication. 

The chief sites of exit are the ankle and the foot — particularly the 

1 Bibliography : Bloch, Allg. med. Ctr.-Ztg., 1899, lxviii., p. 729 ; Foulkes, Brit. 
Med. Jour., 1898, ii., p. 236; Fox, T., Lancet, 1879, i., p. 330; Harrington, Brit. Med. 
Jour., i., 1899, p. 146; Mackenzie, Tnd. Med. Record, 1898, p. 326; Manson, Brit. Med. 
Jour., 1895, ii., p. 1350, and Tropical Diseases, p. 551 ; Perrin, Annales, 1896, s. 3, vii., 
p. 131 ; Roux, Traite prat, des Mai. des Pays Chauds, 1888, iii., p. 553 ; Scheube, Diseases 
of Warm Countries p. 379 (bibliography). 



DBACONTIASIS. 895 

heel — but in rarer cases the leg, thigh, buttocks, penis, scrotum, hands, 
trunk, neck, and face may be selected. There is usually but one worm 
in a single subject of the disease, but the number may be indefinitely 
large in persons exposed. 

Etiology. — The disease is produced by the ingestion of water con- 
taining the larvae of the parasite. Though denied, it seems highly 
probable that it may obtain access also by a traumatism inflicted at a 
date prior to that of invasion. The fact that nearly two-thirds of all 
cases occur in the foot is not without significance. Harrington ob- 
served the disease on the backs and loins of water-carriers where the 
leathern sacks come in contact with the body. Young filarige have 
been seen penetrating the microscopic Crustacea in fresh water, the 
later ingestion of which in drinking-water is supposed to be effective 
in the production of the disease. 

Persons of both sexes and all ages are liable to be invaded ; but the 
disease is of more frequent occurrence in the rainy season, and in male 
negroes and day laborers. 

Pathology and Natural History of the Worm.— The female 
worm alone produces the disease. It is when mature a yellowish-white 
cylindrical filament, gradually tapering toward the caudal extremity, 
averaging 60 to 80 centimetres in length and 0.5-1.7 in breadth, the 
body being extremely extensible by reason of the elasticity of its 
cutaneous envelope. The cephalic extremity is rounded and terminates 
in an oval shield-like disk in which is a centrally placed triangular 
oral orifice. There is a small papilla on each dorsal and ventral edge 
and six smaller on the borders of the shield. While there is a straight 
intestinal tract extending through the body of the parasite, its bulk is 
composed of an enormous uterus which is capable of containing, accord- 
ing to estimates made, between eight and ten millions of embryos. 

The embryos without decidua are flatfish, possessing a long awl- 
shaped tail, a three-lipped mouth, and a digestive canal. They are 
capable of surviving for a week in water : ancl longer in moist earth or 
water polluted with material which provides them sustenance. Manson 
states that the embryos, when they have obtained access to the water, 
transfer themselves to the body-cavity of the cy clops quadricornis, 
fifteen or twenty at a time inhabiting the host, without apparent incon- 
venience to the latter. Soon the exuvium is shed for two or three 
times, the tails drop off, the worms acquire a cylindrical shape, and* 
develop a tripartite arrangement of the caudal extremity. 

In from ten to a maximum of fifteen months the maturity of the 
female which has been impregnated is attained, and the parasite finds 
its way from muscles or other tissues in which she has been lodged or to 
which she has travelled to the surface of the body. 

The Diagnosis (to be made in countries where the disease is 
endemic) is based upon the discovery of the worm. 

Treatment. — The usual method of treatment by the natives of the 
countries named is to secure carefully the head when it appears, and to 
tease out the worm very gently day after day until the entire body is 
extracted, securing the accessible portion by winding it about a bit of 
stick or of paper. Continuous irrigation of the wound is both recom- 



896 PARASITIC AFFECTIONS. 

mended and practised where the disease is common. Tincture of 
asafoetida has also been employed to destroy the parasite. 

Manson 1 has protested against winding out the guinea- worm, stating 
that at best this process merely shortens by a few days the duration of 
the treatment in case the parasite is situated properly in the tissues 
without twists or turns, or if it has arrived at a stage of life when, 
having discharged its young, it is ready to come out spontaneously. If, 
as is often the case, the worm is twined and twisted among the tissues, 
and if she is still emitting her young, she will resist traction, a process 
which will result often in rupture. In consequence of rupture at this 
time myriads of young escape into the tissues, producing violent inflam- 
mation, which is accompanied frequently by secondary infection and 
possibly by sepsis. To determine if the worm is ready to come out 
spontaneously, the opening of the tumor may be douched for a number 
of minutes at a time, several times a day, by dripping cold water over 
it. When under the influence of this douching the worm no longer 
emits young careful winding out is not objectionable. 

The accepted treatment is that devised by a French naval surgeon, 
£mily. The swelling produced by the worm when she ajuproaches the 
skin and before she has pierced it, is injected in several places with a 
solution of mercuric chloride (1 : 1000). This kills the worm, which 
may be absorbed subsequently, or if cut down upon a day or two later 
her body can easily be withdrawn. In case the head of the worm 
be already protruding, the solution may be injected directly into her 
body, which is removed easily the following day. A number of cases 
have been treated successfully by this method, and with no disagreeable 
results in the way of pain or inflammation. This method also reduces 
the time of treatment from not less than four weeks to the much shorter 
period of four or five days. 

The Prognosis is favorable, save in cases in which septicemic symp- 
toms develop as a consequence of coccogenous infection. 

CRAW-CRAW. 2 

(Kro-kro, Kra-kra. Ft., Papulose filarienne.) 

Craw-craw is a term employed by the natives of the West African 
coast for the designation of several diseases of the skin, including 
scabies, ringworm, eczema, and dermatites of various types, occurring 
among negroes. Most authors agree that great confusion prevails 
respecting the affection to which the name should strictly be limited. 

O'Neil believes that the title includes a disorder attributable to the 
presence of a filariform parasite, pustules and papules similar to those 
found in scabies occurring in the regions affected. The filarise found 
by him in the summit of scraped papules were from T J- ¥ to 2tV o" °f an 

1 Brit. Jour. Derm., 1896, viii., p. 37. 

2 Brault, Annates, 1899, s. 3,,x., p. 226. Collineau, Rev. Mens, de l'Ecole d'Anth- 
ropol. de Paris, 1900, p. 84. Emily, J., Arch, de MeU naval., 1899, lxxi., p. 54. 
Manson, Tropical Diseases, p. 563. Scheube, Diseases of Warm Countries, p. 522. 
O'Neil, Lancet, 1875, i., p. 265. Plehn, Die Kamerun-Kuste, Berlin, 1898, pp. 286, 
et seq. 



CYSTICERCUS CELLULOSE CUTIS. 897 

inch in dimensions, with two black markings at the cephalic extremity. 
The eruptive symptoms declined when the subject of the disorder 
visited a cooler climate and returned when there were fresh exposures 
to tropical temperatures. Manson suggests that the parasite may have 
been filaria perstans. 

Emily describes craw-craw as beginning with the appearance of 
reddish-tinted macules of a pruritic character, ultimately forming large, 
coin-sized ulcers, with reddish areolae, clean-cut edges, and granular 
secreting floor furnishing a dense crust. 

The ulcers of craw-craw are commonly multiple, may occur on any 
part of the body, but especially upon the limbs, and are complicated 
and masked by the results of scratching, as the itching is often intol- 
erable. 

The " Coolie - itch," described by Xicholls, is a strictly papular 
disease, without development of vesico-pustules. 

Scheube and his colleagues believe that Plehn's dermatitis nodosa 
observed on the Cameroon coast is wholly different from craw-craw, 
though described under that name. The former is a strictly papular 
disease, the nodules being pin-head to pea-sized, occurring on the inner 
faces of the thighs, the scrotum, the inguinal folds, and the gluteal 
region. About two out of ten negroes are affected. The disorder is 
distributed by scratching. No filarial were discovered. 

Etiology. — The exact cause of the disease in all probability differs 
in different cases. The affection, as described by all writers, is both 
contagious and auto-infectious. 

Treatment is by cleanliness and the employment of appropriate 
parasiticides. 

The Prognosis is, in general, favorable, though in some of the cases 
described by Plehn the patients were in a pitiable state. 



CYSTICERCUS CELLULOSE CUTIS. 

Cysticercl have been recognized in the skin and subcutaneous tissues 
by Rokitansky, Guttmann, Schiff, Ferreol, Duguet, Lewin, 1 and other 
observers. The subjects are usually consumers of uncooked meats, 
especially of pork. In these cases one or many oval or roundish, firm, 
elastic, cutaneous or subcutaneous, pea- to walnut-sized tumors, isolated 
or disseminated, unproductive of pain, project from the general level, 
and are enveloped by an unaltered integument. They occur upon the 
trunk and the extremities. They remain in this condition without 
change for years, and may accompany cysticerci of the brain and other 
portions of the body productive of the serious disturbance of the econ- 
omy which such invasion may determine. If the skin-tumors be opened 
and their contents examined, the parasite (which is the scolex or hydatid 
of taenia solium) will be recognized as an ampulliform sac, with a 
cephalic appendage, reentrant or projecting, and provided with four 
suckers and a coronal of hooklets. By no external characteristics could 

1 Cf. Vierteljh. f. Derm. u. Syph., 1894, vol. xxvi., pp. 70 and 217, for review of 
literature. 

57 



898 PARASITIC AFFECTIONS. 

such tumors be distinguished from others of similar size and external 
appearance. Only in the rare cases of nervous complication could a 
suspicion arise based upon the real character of the disorder. Respect- 
ing this matter, however, the diagnostician is in no worse position than 
when called upon to recognize cysticerci of the viscera. Cysticerci of 
the liver are distinguished during life, and subsequently removed by 
operative procedures. 

The Diagnosis is from gumma, lipoma, epithelioma, and sarcoma. 
The first occurs only in the syphilitic ; the second has a peculiarly 
uneven surface and firm feeling ; the third is largely facial in situation ; 
and the last is of a malignant character and relatively rapid career. 

ECHINOCOCCUS. 

Weyl and Geber state that the parasite, echinococcus (larva or hydatid 
of the taenia echinococcus of the dog), is found in the human skin. Of 
336 cases reported by Davaine, the parasite occurred thirty times in 
muscular aud subcutaneous tissues, more often in women than in men. 
The softish, fluctuating tumors or vesicles produce a disagreeable sen- 
sation of tension, and they undergo fatty or other metamorphosis after 
the death of the encapsulated parasite that usually occurs in from one 
to two years. Exploration of the superficially seated, fluctuating 
tumor, covered with unaltered integument, usually demonstrates its 
nature. 

DISTOMA HEPATICUM. 

Kuchenmeister 1 reports three instances in which the embryos of the 
large liver-fluke were encapsulated in subcutaneous tissue. The tumors 
were painful or painless, and occurred on the head, trunk, and ex- 
tremities. 

LEPTUS. 

(Leptus Autumnalis, Harvest-bug, Mower's Mite. 
Ft., Koitget ; Ger., Erntemilbe.) 

The leptus (Figs. 100 and 101) is a minute, reddish or yellowish-red 
insect of the family Trombidce, visible to the naked eye, and found in 
summer and autumn clinging to bushes and grasses. It is found both 
in America and in Europe. It attacks man only after its accidental 
location upon the skin, where it perishes in the course of a few hours. 
In such situations, however, it induces considerable irritation, betrayed 
in erythematous, urticarial, papular, and even eczematous symptoms, 
accompanied by pruritus of various grades. The parts chiefly affected 
are the ankles, legs, arms, and feet. The mite may be seen in the skin as 
an orange-reddish or brick-reddish point, which represents often the body 
of the insect, its head being buried in the aperture of a follicle beneath. 
Examined after extraction, it is seen to have a relatively large cephalic 
extremity. It has a short, cylindrical, and conical haustellum, composed 
of fused double maxillae ; and two strong, hooked, five-jointed palpi ? 

1 Loc. cit. 






LEPTUS. 



899 



which can be rolled up. There are also two hatchet-like mandibles. 
It has a well-rounded or oval body 0.3558 mm. long and 0.32 mm. 
broad, provided with three pairs of legs. It is found upon the lower 
limbs, and also upon the scalp and every other part of the body. 



Fig. 99. 




Leptus Americanus. 



According to Duhring, children are especially liable to its encroach- 
ments. The disorder is relieved by the application of balsam of Peru 
in olive-oil, carbolated oil, spirit of camphor, or other mild stimulant 
or parasiticide. 



Fig. 100. 



Fig. 101. 





Leptus. (After Kuchenmeister.) 



Rouget. 



There are several species of leptus {leptus Americanus, leptus irri- 
tans) and other insects living on shrubs and grasses that, especially in 
the months of July and August, attack the human skin. 



900 PARASITIC AFFECTIONS, 

Leptus Americanus (krithoptes monunguiculosus ; Fig. 99) is named 
by Weyl and Geber as the larva of a mite that annoys laborers 
in barley. It is yellowish white, oblong or oval in form, averaging 
0.022 mm. in length. There is a protrudible tubular haustellum, 
enclosed by serrated mandibles. On each side are five-jointed palpi. 
There are four pairs of feet — two on the cep halo-thorax ; two, abdom- 
inal in situation — all articulated to the epimeres. The tarsus of the 
first part terminates in hooked claws ; the others have haustellum disks 
on stems. Between the first and second pairs are swinging clubs, indi- 
cating the larval condition. 

Dipterous Larvae in and beneath the Human Skin. 

There is no dipterous insect pecular to man alone, but a number of 
cases are on record in which the ova of several species of oestrus have 
been deposited in the skin, and larvae subsequently been formed. The 
oestrus bovis (Gadbreeze), or gad-fly, in the most common of these. 
Usually after the ova are deposited by the insect a painful swelling 
occurs, which may change from one point to another. When suppu- 
ration is induced the larvae can be removed by pressure upon the boil. 
Walter Smith, 1 of Dublin, has described such a case, in which the 
swelling upon the ankle of a girl, twelve years old, moved to the 
elbow, and there discharged a white grub, nearly an inch in length. 

Fig. 102. Fig. 103. 

CL 



CEstrus : a, the larva, natural size; b, Larvae removed from the body of a child, 

some of the segments seen under a lens, Of the exact size, after several days in alco- 

and showing the lines of minute projec- hoi: a, as seen from side; b, as seen from 

tion; c and d, the terminal ends of the beneath, 
insect. (After Abraham.) 

Birdsall 2 described a specimen sent him from Gaboon, on the West 
Coast of Africa, in which two worms escaped from between the middle 
and the ring fingers of one hand; another workman having had a 
similar accident occur upon the leg. The fly the ova of which had 
been deposited in these two cases was said to attack the gorilla, and 
members of a native tribe engaged in capturing these animals were 
reported as being commonly troubled in the same way. The worms 
sent to Birdsall were, respectively, one-fourth and one-half of an inch 
in length and about one-eighth of an inch in thickness. 

1 See Report of Internal Med. Congress, Arch, of Derm., January, 1882. 



N. Y. Med. Record, March 18, 1882, p. 298. 



IXODES. 901 

Abraham, of Dublin, also examined and reported upon a similar 
case, the specimen having been sent to the editor of the London Medi- 
cal Press and Circular, from Portsalon, Letterkenny. 

Several specimens illustrating these accidents have been sent to the 
authors. The larvse represented in Fig. 103 were removed from the 
body of an infant in Nebraska. The muscidce (flesh, house, stable, 
dung, and other flies) have unarmed maxillse, and are unable to wound 
the uninjured skin. The pregnant female seeks, therefore, to deposit 
her ova where the larva?, equally unprovided with developed jaws, can 
most readily secure nutriment. Hence, open w T ounds and the tender 
skins of newborn infants when exposed in the summer season, are 
liable to become the depots of such ova. 

The ova of other species of muscidce and cestridce (according to 
Geber, of the former, Lucilia Ccesar, in America ; Stomoxis Calcitrans, 
in Africa ; and Sarcophila Wohlfarti, in Russia ; of the latter, Derma- 
tobia Noxalis, Cuterebra, and Hypoderma) are occasionally found in the 
skin and subcutaneous tissue. Severe cases are reported from Texas, 
in which larvae were expelled in great number from the nares after 
inhalation of chloroform. 

Larva Migrans or Gastrophiltjs. — Lee, 1 Crocker, 2 and other 
observers describe a serpiginous disorder occurring in Austria, Russia, 
Arabia, and Bulgaria. The larva, having been deposited by the mother 
insect in an exposed part of the skin (buttock, cheek, thigh, trunk), 
travels beneath the surface at the rate of an inch or more daily, in 
curves and gyrations, its travels extending over months and in one 
instance for two and a quarter years. Its gallery is marked by a red- 
dish line, fading in a few days at the " passive end," while the larva is 
from a quarter of an inch to an inch beyond the " active end. 7 ' Its 
course is arrested by suppuration, which does not seem to occur spon- 
taneously. The parasite may be located as a dark point when the 
skin is pressed, as in bioscopy. The effective treatment has been by 
excision. 

IXODES. 

(Wood-tick. Fr., Pon de Birs, Tique ; Ger., Holzbock.) 

Several species of tick are recognized, such as the Rhipicephalus 
Annul atus (cattle-tick), Amblyomma Americanus, Ixodes Uni- 
punctatus, and Ixodes Ricinus (wood-beetle), the last named being 
more common in Europe. In America wood-ticks are found in wooded 
districts, especially where pine- and fir-trees are growing. The female 
occasionally attacks the human skin by thrusting into it her beak, 
armed on either side with a maxillo-labial projection having recurved 
hooklets, the mandibles also presenting similar obstacles to the forcible 
extraction of the head. After suction of the blood from beneath, the 
body of the tick swells to the size of that of a pea or small bean, and 
may remain for several days in this position. At such times the para- 

1 London Clin. Soc. Trans., 1875, viii., p. 44. 

2 Treatise, 3d edition, p. 1388. 

3 Cf. Jour. Cutan. Dis., 1898, xvi., p. 297. 



902 PARASITIC AFFECTIONS. 

site may be mistaken for a small pedunculated tumor. Forcible 
attempts at extraction of the intruder are liable to detach the mandibles 
from the body, and thus leave them as the source of future irritation 
and even disagreeable inflammatory symptoms in the site of the punc- 
tured wound. On applying over the tick a drop of spirit of turpen- 
tine or benzine the head is spontaneously retracted and the body falls 
from its position. Soldiers on the plains of the United States accom- 
plish the same end with the juice of tobacco. The sensation produced 
at the moment of the insertion of the beak of the insect is said to be 
so trifling as often to pass unnoticed. 

PEDICULOSIS. 

(Lat. pediculus, a little foot.) 

(Phtheiriasis, Morbus Pediculosis, Lousiness. Fr., Phthi- 
riase ; Maladie pediculaire ; Ger. f Lausesucht.) 

Symptoms.- — Lice belong to the order Rhynchotta ; subdivision Par- 
asitce ; family, Pediculidce. They are apterous, provided each with 
two eyes, and have an oral appendage capable of both inflicting wounds 
and producing suction. The lice infesting the human body are recog- 
nized as belonging to three varieties, those of the head, of the body, 
and of the pubes. Of the disorders to which they give rise, it may be 
said in general that the lesions presented differ according to the region 
invaded, to the multiplicity of the intruders, and to the length of time 
during which their ravages have been inflicted. Such lesions, however, 
are those which have been already studied in connection with eczema, 
urticaria, and the similar disorders resulting from external irritation. 
Their special peculiarities in pediculosis are owing solely to the nature 
of the exciting cause and to the mode of its operation. 



Pediculosis Capillitii. 

(Parasite, the Head-louse.) 

The head-louse (Fig. 104) is usually of a grayish color, but differs 
slightly with the hue of the hair on the part which it frequents. Its 
head presents indistinctly the outline of a trefoil, and is provided with 
two hairy antennae (each of five articulations) and with two eyes. Its 
thorax is relatively narrow, with six tracheal stigmata and three hairy 
legs on either side, the legs being provided with tarsal hooklets. The 
abdomen is divided into seven segments, defined by blackish indenta- 
tions on either side. The males are fewer and smaller than the females, 
and they present upon the dorsum an ano-genital orifice and a large 
conoidal penis and testes. The females are provided with ovaries and 
with an anal aperture in the terminal abdominal segment. Coupling 
is performed with the male beneath. 

The ova or " nits " (Fig. 105) are whitish bodies of oval contour, 
that are glued to the hairs by a cylindriform sheath of chitin which 
completely encases each filament. They are deposited in series, as the 



PEDICULOSIS. 



903 



Fig. 104. 




Pediculus eapillitii— male. 
(After Kuchexjieister.) 



female traverses the hair from its insertion to its distal extremity, so 

that the oldest are in general the nearest to the scalp. The young 

escape from the ova in from three to eight days, 

and arrive at maturity in from eighteen to twenty 

days. A single female, according to Kaposi, can 

lay fifty eggs in six days, and thus in eight weeks 

have a progeny of five thousand lice. 

Head-lice usually limit their habitat to the 
scalp, though, rarely, in elderly men with long- 
hair reaching to a full beard, they may encroach 
upon the latter. They infest every portion of 
the scalp, but find the 
Fig. 105. region of the greatest pro- 

tection upon the occiput. 
They are found upon chil- 
dren and adults of both 

sexes, but are furnished best with lodgement 
upon the scalps of girls and of women covered 
.'}' with long and luxuriant hair. The lesions 

observed upon a scalp thus inhabited vary 
according to the age and vigor of the colony. 
They are few or numerous, discrete or confluent 
pustules or bullae ; the surfaces are excoriated 
by scratching and oozing with serum, pus, or 
blood ; the crust varying in character according 
to the nature of the desiccated exudate and 
sebaceous matters. Often the picture presented 
is a conglomerate of an artificial eczema and 
seborrhoea. 

The ova, or "nits," are usually abundant 
upon the hairs of an infested head, and scarcely 
will escape the attention of a close observer. 
They are not to be mistaken for the exfoliated, 
epithelial, and fatty plates seen in seborrhoea 
sicca, disseminated among the hairs and often 
perforated by hairy filaments, since the former 
are glued firmly in position and resist the 
bristles of the hair-brush. The peculiarly 
nauseating odor of the louse-infested, pustule- 
and crust-covered scalp is not to be confounded 
with that due to favus of the same region. 

In aggravated cases the post-cervical ganglia 
express, by their increase in size, the degree 
to which the local irritation has been pushed. 
The itching is usually severe, and in cases of long persistence in chil- 
dren may produce the usual systemic symptoms of prolonged local 
irritation. Children and patients of impoverished health and with 
poor hygienic surroundings are believed to exhibit the disease in severer 
grades than others ; but this, if indeed a fact, must at least in part be 
due rather to the more favorable conditions for development and 



Ova of head-louse attached 
to hair : 1,2, 3, ova ; a, a, chi- 
tinous cylinder surrounding 
a pilary filament; b, chiti- 
nous sheath of nearly mature 
ovum. (After Kaposi.) 



904 PARASITIC AFFECTIONS. 

multiplication of the parasites that are presented in filth-accumula- 
tion and lack of cleanliness. In the public charities of large cities 
children affected with pediculosis capillitii are presented every week 
who come from the lowest social grades of the population and from the 
filthiest quarters. In these children it is not observed that the general 
health of the patients is a factor in the severity of the affection. 

The Diagnosis of pediculosis capillitii is a matter of importance 
however simple of accomplishment, since many cases of supposed 
"pustular eczema of the scalp" have vainly been treated by one 
physician with internal remedies^ addressed to the systemic vice 
assumed to be responsible for the 'disease which another has relieved 
after the discovery of a few head-lice. The hairs should always be 
raised and separated, the scalp carefully be inspected, and the presence 
of any parasites, and especially ova or " nits " fastened to the hairs, be 
ascertained. Whether the lice have preceded or followed the eczema- 
tous state (and each of these conditions may be noted) is a matter of 
minor importance. Pustules about the nares and lips, especially of 
young girls, are often significant of pediculi of the occipital region, the 
lesions being due to picking and scratching the face under an impulse 
to relieve pruritic sensations of the scalp induced by the presence there 
of lice. 

Tre&tnient. — The indications in the treatment of pediculosis capil- 
litii are the destruction of all parasites with their ova 3 and the relief 
of the induced inflammatory condition of the scalp. Generally, re- 
moval of the former is followed by spontaneous disappearance of the 
latter. For the destruction of the lice the most popular remedy in 
the United States is petroleum (not kerosene), pure or with equal parts 
of balsam of Peru (which gives it an agreeable odor), poured over the 
scalp in quantity sufficient to cover it without overflow upon the brow, 
temples, and neck. It should be rubbed in with a piece of white 
(undyed) flannel. At the end of from twelve to twenty-four hours the 
lice are destroyed, and the ova are rendered incapable of development. 
This treatment is followed by a thorough shampoo with tincture of green 
soap, or with toilet-soap and hot water ; after this operation the scalp 
may require a bland unguent, such as vaselin, or a small quantity of 
scented castor-oil, either pure or in combination with spirit of wine. 
Kaposi employs petroleum as a parasiticide in combination with olive- 
oil and balsam of Peru : 5 parts of the first, 1\ parts of the second, and 
1 part of the third. Cutting the hair of women and children is unnec- 
essary, as patience and gentleness with the use of the comb will dis- 
entangle the most matted masses after the lice have been destroyed. 
Other remedies are employed locally for a similar purpose, of which 
the most popular are staphysagria, 1 drachm (4.) of the powdered seeds 
to the ounce (30.) of vaselin, but especially in decoction ; tincture of 
cocculus indicus ; carbolic acid in oil or water ; sabadilla ; the ethereal 
oils ; and mercurials in ointment and solution, including the mercuric 
oleates. In cases in which but a few parasites have found their way 
to the scalp, and that recently, nothing more is requisite than careful 
use of a fine-tooth comb, scrubbing the scalp with a strongly scented 
alcoholic perfume, and final bathing with soap and hot water. 



PEDICULOSIS. 905 

The ova adhering firmly to the hairs can be removed by soda or 
borax lotions, alcoholic solutions, or dilute acetic acid, which are sol- 
vents for the gluey material by which the " nits " are secured in place. 

Pediculosis Corporis. 

(Pediculosis Vestimenti, Phtheiriasis, Parasite, the Body- 
louse.) 

The parasite in this disorder inhabits exclusively the clothing worn 
next the body. In anatomical peculiarities it resembles the pediculus 
capillitii already described, being, however, larger in size, the .females 
also larger than the males. The thorax is separated from the abdo- 
men, the latter being hairy, yellowish at the margins, 
and provided with eight segments. The eyes are Fig. 106. 

black and very prominent in both sexes ; and the 
periods requisite for the maturing of the ova and 
young are those named respectively in connection 
with head-lice. In color they vary from a dirty 
white to a light-grayish hue when undistended with 
blood. In the reverse of this last-named condition 
they may be recognized as having a dull-reddish or 
a purplish color, when they are also more indolent 
in their movements. They measure from 2 to 3 mm. 
in length and 1 to 1.5 mm. in breadth. The female 
lays from seventy to eighty eggs, from which the 
young are produced in from three to eight days, and 
are capable of reproduction in a fortnight more. 

They inhabit the seams of undergarments, where Pediculus corporis— 
their ova are also deposited ; but in coarse woollen k^henmekter!) 
or flannel shirts they find sufficient shelter in the 
meshes of the material of which the clothing is made ; this they leave 
temporarily, solely for the purpose of obtaining nutriment from the 
skin of their host, and hence are not recognized upon the free surface 
of the integument. Upon rapid removal of the clothing of an infested 
individual a few lice may occasionally be encountered, hastily seeking 
a place of refuge, though this is rather the exception to the rule. It 
thus may happen that a louse-bitten patient will not exhibit the source 
of his trouble to his physician after a recent and complete change of 
clothing. The greater then the importance of being able to recognize 
the clinical features of the malady in the absence of the parasite. This 
recognition is comparatively easy to one who has made himself familiar 
with the symptoms of the disorder. 

The manner in which the louse is enabled to supply itself with the 
blood of man has been studied by Swammerdam, Landois, Schjodte, 
and Tilbury Fox. The last-named author has summarized the ob- 
servations of the others, and the results he gives may briefly be de- 
scribed as follows : 

Swammerdam's original view that the louse is not provided with 
mandibles bv which it can inflict a wound, but with a haustellum by 




906 PARASITIC AFFECTIONS. 

which the blood is sucked up to the head of the parasite, is confirmed 
by Schjodte. This observer, examining the head of the louse from 
behind with reflected light, discovered that the parts of the head re- 
sembling mandibles in appearance were really situated beneath its skin. 
He applied to the integument lice which previously had been starved, 
and watched each as, with retracted limbs, arched back, and head in- 
clined obliquely downward, it repeatedly projected forward and re- 
tracted through the extreme end of its head a " small, dark, narrow 
organ," by which it was firmly held in place. A triangular blood-red 
point soon became visible in front of the eyes, rapidly and alternately 
contracting and dilating, and followed by energetic peristalsis of the 
gastro-intestinal tract. If the head then be cut off in front of the eyes, 
and the haustellum carefully be extracted, the latter can be recognized 
as a brownish protrusion, armed with terminal recurved hooks, from 
which depends a delicate membranous tube varying in length. " It 
seems that the mouth is like that in the rhyncotta generally, but differs 
in the circumstance that the labium is capable of being retracted into 
the upper part of the head, and has a fold in it when so retracted. In 
order to strengthen this part, a flat band of chitin is placed on the 
under surface ; and it is thinner in the middle in order that it may bend 
and fold a little when the skin is not extended by the lower lip. The 
latter consists of two hard lateral pieces, of which the fore-ends are 
united by a membrane, so that they form a tube, of which the internal 
covering is a continuation of the elastic membrane on the top of the 
head. Inside its orifice are a number of small hooks, which assume 
different positions according to the degree of the protrusion ; and if 
this be pushed to its highest point, they form a collar of hooks curved 
backward like barbs. The pediculus first inserts its labium into a 
sweat-pore and protrudes the lip. When the hook is securely attached 
to the parts around then the first pair of setae (the real mandibles trans- 
formed) are protruded, and these are toward the point invested by a 
membrane so as to form a closed tube, from which again is exserted a 
second pair of setae or maxillae, which form a tube and end in four 
small lobes placed crosswise. The whole forms a membranous tube, 
along the walls of which retiform mandibles and maxillae are placed as 
longj narrow bands of chitin. This tube can be lengthened or shortened 
at pleasure." 

This explanation of the mode in which the louse attacks the skin is 
probably true of each of the varieties which infest the human body. 
The invaded follicle, after the withdrawal of the haustellum, becomes 
the seat of a circumscribed hemorrhage. None of the anatomical 
peculiarities described above, however, completely explains the char- 
acteristic pruritus of pediculosis corporis, for it can scarcely be ques- 
tioned that it is not merely at the moment of attack or penetration 
that the suffering of the victim is greatest. The pruritic condition of 
the louse-wound persists, indeed usually attains its maximum, after 
withdrawal of the pediculus, and is without doubt greater than that 
awakened by merely mechanical puncture of the epidermis. Anyone 
who Avill compare the skin of a louse-infested patient with that of one 
who has been subjected to the acupuncture process employed among 






PEDICULOSIS. 907 

the lower classes of Germans, and by them known as " baunscheidt- 
ismus," can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate, irregularly from each louse-wound, and they 
may be commingled with minute papules, transitory wheals, or, in rare, 
aggravated cases, with the typical signs of diffuse eczema. All are 
produced by scratching in order to relieve the pruritus. Crusts, often 
composed of desiccated blood, rarely of serum or pus, minute and cap- 
ping the wounded follicle, or linear and coextensive with the excoria- 
tions produced by scratching, are generally conspicuous. In older cases 
these lesions are followed by the usual sequel, pigmentation, the latter 
being a partial indication of lousiness which has long been tolerated. 

In America it is rare to note the severe and intense forms of the 
malady, resulting from long-continued neglect of the skin, that occur 
in Germany. In these cases follow : dermatitis, rupioid crusts, furun- 
cles, abscesses, carbuncles, and ulcers, resulting in serious implication 
of the skin which may persist for weeks after the clothing has been 
freed from lice, and finally leave a deep-tinted, diffuse pigmentation of 
the skin-surface, suggesting that of the negro or of the patient affected 
with Addison's disease. 

The Diagnosis is a matter of importance. Patients will visit physi- 
cians, claiming that they have suffered from a " humor of the blood," 
who have been swallowing drugs for a long period of time, in the vain 
hope of obtaining relief, with lice, at the very moment of uttering the 
complaint, crawling over their persons. Even those of good social 
position and cleanly habits will occasionally suffer after accidental 
contacts in the tram-car or railway-carriage, the hotel, the theatre, 
or other places of public resort. There are certain points to be 
carefully noted in this connection. Excoriations over the nucha, 
about the shoulders, loins, buttocks, and external faces of the thighs, 
all visible at the same time, are highly suspicious symptoms; as an 
eczema, when equally diffuse, is sure to be accompanied at some point 
by perfectly classical features ; and generalized pruritus is exceedingly 
rare, its localized varieties concerning chiefly the regions about the 
mucous outlets of the body. There is a picture highly suggestive of 
pediculosis exposed to the eye when the trunk of an infested patient 
is viewed from behind. The lesions are more discrete, more irregularly 
distributed, and more intermingled with long scratch-marks, reaching, 
for example, quite over the point of one shoulder, than in most dis- 
orders with which pediculosis vestimenti could be confounded. Here 
and there minute blood-specks tell a significant tale. When clinical 
patients exhibit syphilodermata interspersed among characteristic lesions 
of pediculosis corporis the students themselves in such cases can ordi- 
narily point out the particular symptoms referable to the separate dis- 
orders present. 

In private practice it is usually advisable, for obvious reasons, to 
secure the corpus delicti before informing the sufferer of the nature of 
his or her complaint. In the case of male patients it is well to take a 



908 PARASITIC AFFECTIONS. 

position in the rear, and when the underclothing is drawn well up from 
the shoulders a careful scrutiny of it may be made while the applicant 
for relief supposes that attention is directed instead to his person. 

The Treatment of the disorder concerns largely the clothing. The 
latter requires immersion in boiling water, or it may be wrapped in 
paper and subjected to a temperature in an oven (160°-175° F.) 
sufficient to destroy the lice and their ova. In case of recurrence of 
the malady the clothing is to be again subjected to the same process. 
Usually the resulting irritation of the skin promptly subsides. When 
several members of one family suffer all clothing worn must be sub- 
jected to similar treatment. If the skin has been unusually tormented 
by scratching, warm alkaline baths will afford some comfort, and they 
may be followed by a bland unguent or by one of the dusting-powders. 
For immediate use, before the clothing can be rid of the intruders, a 
small cheesecloth bag containing sulphur in stick or in powder may be 
worn beneath the underclothing, or the powder may be dusted in the 
clothing and rubbed over the body ; or a parasiticide ointment may be 
ordered as recommended by Duhring, prepared by adding 2 drachms 
(8.) of freshly powdered staphysagria to the ounce (30.) of hot lard, 
strained and cooled. The surface of the skin may also be anointed with 
carbolic acid dissolved in oil or in water. 

• 

Pediculosis Pubis. 

(Crab-louse. Parasite, the Pubic Louse. Fr., Morpion.) 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 
including the eyebrows, the eyelashes, the axillae, and the moustache 
and beard, the hairy chest, and the hairy legs of men. The body 
of the pubic louse (Fig. 107) is smaller than either of those described 
above. Its head is also attached more closely to its thorax, having a 
shape which is compared with that of a violin. The thorax is not 
distinctly separated from the abdomen, and of the six stout legs with 
which the louse is provided, the second and third pairs are conspicuously 
powerful and armed with relatively large hooks at the tarsal extremity. 
The resemblance of the latter to the claws of a crab has given to this 
creature the common name of " crab-louse." The lateral abdominal 
indentations are much less distinct than in the other varieties ; and 
the blackish marginal marks of body- and head-lice are here scarcely 
apparent. The abdomen is also much elongated, having a more rounded 
contour. The pubic louse is provided on its lateral borders with eight 
short conical feet, terminating in bristles. It is also distinguished from 
the others of its family by the length of its anal bristles and by the 
peculiar shield-shaped carapace which covers nearly one-half of the 
dorsum. The male is from 0.8 to 1 mm. long, and from 0.5 to 0.7 
mm. wide, being thus from 1 to 1.5 mm. smaller than the female. 

The pubic louse is much more inactive than the others, and does not 
ordinarily escape its pursuer. It buries its head deeply in a follicular 
orifice, and steadies itself in this position, where it may remain for 




PEDICULOSIS. 909 

some time, by grasping the adjacent hairs with its short and powerful 
claws. A moderate degree of force is required for its dislodgement 
from this favorite position, and when removed its grasp of the hair to 
which it clings is so firm that the latter usually slides for its entire 
length through the claw of the louse. Occasionally it may be found 
creeping over the skin or clinging to hairs at a distance from the skin- 
surface. The pyriform ova are smaller 
than those of the head-louse, though hav- _ FlG - 107 - 

ing a similar color, and are, like the lat- 
ter, attached to the hairs by a firm chiti- 
nous glue. 

Pubic lice are usually acquired during 
the contacts incidental to the sexual act ; 
are, hence, more frequently encountered 
among adults ; but may, without question, 
be transmitted mediately by occupation 
of beds and covering which have been 
used by infested persons. They are thus, 
though rarely, found in children of both 
sexes. 

The lesions induced are those produced Pedicu i us pubis ' ^ T schmarda.) 
by the wounds inflicted by the parasites 

and by constant scratching, though these are rarely severe. In a few 
cases a severe dermatitis follows the ravages of the lice, but in such 
event the complication is chiefly owing to unnecessarily severe self- 
treatment of the disorder, patients being often morbidly anxious in 
their efforts to rid themselves of the pests. 

The Diagnosis of pediculosis pubis is between eczema and pruritus 
genitalium. The disease last named is, in both sexes, accompanied by 
itching, and that often of intense grade ; but when this is diffuse and 
symmetrical in distribution it is not limited particularly to the hairy 
parts. Eczema of the genitals is not often produced by parasites of 
that region, and it may readily be recognized by its characteristic fea- 
tures. Both disorders are often, indeed, limited to symmetrical patches 
upon the side of the scrotum or one labium. The discovery of the 
parasite, however, in pediculosis pubis is always essential, and requires 
merely careful inspection and a good light. The lice may be recognized 
either at or near the point of implantation of the hairs, which also dis- 
play ova except in very recently infested individuals. The reddish 
excrement of the parasites mingled with scratch-marks and excoriated 
papules of small size may also be observed. Patients are often made 
aw r are of their condition by a sensation of crawling over the parts. 
Scratching of the pubic region in adults of both sexes should awaken 
suspicion of the disorder. 

Treatment. — The disorder is treated commonly by the topical appli- 
cation of mercurial ointment, which is a disagreeable and rather filthy 
medicament for this locality. The 10 per cent, oleate may be substi- 
tuted for it, or, even preferably, corrosive sublimate in solution, from 
3 to 4 grains (0.2-0.268) to the ounce (30.). Petroleum and olive-oil 
with balsam of Peru, in the proportions given above in connection 



910 PARASITIC AFFECTIONS. 

with the subject of pediculosis capillitii, furnish an effective combination. 
Staphysagria, carbolic acid, cocculus indicus, or one of the other sub- 
stances used in the disorders occasioned by the animal parasites, 
may be substituted if desired. It is usually better to defer bathing 
until the remedy selected for the destruction of the lice has been ap- 
plied on several occasions, after which a warm water-and-soap ablu- 
tion will commonly end the trouble. It is needless to clip the 
pubic hairs. Should a dermatitis follow, an appropriate treatment 
includes hot bathing and the blander lotions and unguents. 

Macule Ccerule^ (Fr., Taches ombrees, Taches bleuatres), 
are pea- to small-coin-sized grayish stains found on the chest, belly, 
thighs, and upper arms, especially of blonde subjects. They have a 
steel-gray tint, do not disappear under pressure, and are believed to be, 
for the most part, signs of infestation with the pubic louse, though 
occurring in predisposed individuals independently of such invasion. 
Duguet, 1 after inoculations with the juices of crushed pediculi, believes 
that he has demonstrated that the lesions spring from pigment origi- 
nating in the body of the insect. 

Vagabonds' Disease. — This is a term given to the condition of 
the skin recognized among tramps, inmates of poorhouses, and the 
filthy and neglected in general. The skin of such persons is often 
densely indurated, harsh, dry, and deeply pigmented, in consequence 
of much scratching and a consequent hyperemia. This condition is 
produced chiefly by phtheiriasis ; but is often a resultant of the incur- 
sions of several parasites, including those of the bed and of the cloth- 
ing. It is also a consequence of persistent neglect of the bath. 

Pediculi and Acari transferred to Man from the Lower 
Animals rarely thrive in such uncongenial soil, but as a matter of 
exception they occasionally survive such transfer. Thus Goldsmith, 2 
of Vermont, reports the case of a woman affected with intense pruritus, 
who after sweating profusely observed numbers of pigeon- or hen-lice 
emerging from the sweat-pores. Megnin 3 reports similar cases under 
the title Prurigo Dermanyssique, the dermanyssus avium, or gallinoe, 
being the acarus infesting domesticated fowls. The disorder is said to 
be at times epidemic in the vicinity of aviaries and pigeon-cotes, but is 
always of trifling severity. 

1 Annales, 1880, p. 544. 

2 Louisville Med. News, December 31, 1881, p. 320. 

3 Les parasites et les maladies parasitaires chez l'homme, les animaux domestiques, 
etc. Paris, 1880. 






GIMEX LECTULARIUS. 911 

CIMEX LECTULARIUS. 

(Bugs, Bedbugs, Acanthia Lectularia. Fr., Punaise des Lits ; 

Ger.j Bettwanze.) 

Strictly speaking, the bedbug is not a parasite of man, but finds its 
congenial habitat in the bed, bedding, and bed-covering, and the walls 
and floors of apartments occupied by persons of both sexes and all 
ages. It infests also furniture, including chairs, sofas, and the cushions 
of seats occupied in public vehicles and hotels. From the cracks, 
crevices, seams, folds, or other protected points where it has found 
lodgement, it emerges usually at night, for the purpose of securing its 
nutriment in the blood of its victims. It is a pest as ancient as the 
day in which Dioscorides wrote. 

This insect has a rusty or reddish color, this differing slightly ac- 
cording as it is or is not distended with blood. It is an apterous 
member of the order Cimicid^e. It is provided with a blunt-pointed 
head, broadly attached to the thorax; two long, slender antennae; 
and a three-jointed haustellum capable of projection and retraction 
beneath the head. There are three pairs of long, slender legs by which 
it is enabled to accomplish rapid movements. The abdomen is broad 
and flattened, and oval in shape, with nine segments. The parasite 
emits a disgusting odor, which is much more distinct when it is 
crushed. 

The wound inflicted by this bug is accomplished with or without the 
consciousness of its victim, who in the former case is made aware of a 
transitory prick or sting. Soon after, decidedly pruritic, burning, or 
stinging sensations are experienced, and the wound becomes the seat 
of an urticarial wheal. The lesion then, examined soon after the inflic- 
tion of the wound, is seen to be small pea- to bean-sized, and in the 
form of an elevated and circumscribed " button 7 ' or papulo-tubercle, 
either whitish in the centre or exhibiting there also the hyperemia 
which distinguishes its peripheral zone. After the lesion has begun to 
subside and lose its acute features, which may not occur for several 
hours if it be irritated by rubbing or scratching, a minute reddish 
punctum may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 
has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this way 
at times its course upon the integument may for a short distance be 
traced. In cases in which the pests are numerous, as in filthy dwell- 
ings, prisons, ships, and barracks, and when infants have been attacked, 
the resulting eruption is often greatly masked by the scratching and re- 
sulting excoriations of the skin-surface. In this way vesicles, pustules, 
crusts, purpuric blotches, and even skin-infiltrations may be found, 
instead of the rosy or light-reddish typical wheals of recent cases in 
patients with fair, clean skins. 

The Diagnosis is a matter of importance, and upon it may hang a 
professional reputation. Physicians are often consulted respecting these 
lesions by patients who believe themselves to be suffering from "hives," 
" humors/' exanthemata, and even from syphilis. The insect attacks 



912 PARASITIC AFFECTIONS. 

the parts of the body to which access is easy as the patient sits or 
reclines on the back or side, including the buttocks, the thighs, the 
shoulders, the loins, and the neck, in that order of frequency, rather 
more largely than the legs, much less frequently the scalp, the face, and 
the genitalia. The eruption is not to be confounded with urticaria ab 
ingestis, which is more apt to be symmetrical in disposition. 

Treatment. — The eruption is best relieved by the topical application 
of spirit of camphor, alcohol, weak carbolated lotions, or solutions of 
boric acid, 1 drachm to the pint (5. to 500.) Untreated, it disappears 
spontaneously when the source of the disorder is removed. The most 
effective treatment is by prophylaxis, with soap, corrosive sublimate 
solutions in alcohol, and hot water employed over all accessories of the 
dwelling-house inhabited by the insects. Once discovered to be present, 
infested furniture should be scrubbed in all its crevices with a saturated 
solution of corrosive sublimate in alcohol, and bed-clothing be immersed 
in boiling water. 

CULEX PIPIENS, Etc. 

Other insects which may persistently or only occasionally attack the 
human skin are : the mosquito and gnat (Culex Pipiens) ; midges 
(Simulia) ; bees (Apes Melliferve) ; and wasps (Vespid^e). They 
produce by their bites or stings various cutaneous lesions, including 
urticarial wheals, papules, ecchymoses, and in rare cases even ecchymo- 
mata. The lesions produced by the flea are found more often on the 
legs, the neck, or other covered portions of the body. Those of the 
midge and mosquito are seen on the face, the hands, and exposed parts ; 
though, when numerous and voracious, these insects will penetrate the 
clothing for the purpose of obtaining blood. Severe eruptive lesions 
are often seen in America on the faces and extremities of infants and 
children exposed during the night to the incursions of these marauders. 
The skin-symptoms are usually treated locally by aqua ammonia? or 
spirit of camphor. 

The bodies of immigrants newly arrived during the summer season 
in America, from countries where the mosquito is either rare or does not 
exist, often present singular and even formidable evidences of the attacks 
of these insects. The skin, unaccustomed to such depredations and 
quite unprotected, will often be found greatly swollen, and of a light- 
reddish hue suggestive of erysipelas. Here and there bulla? are con- 
spicuous, which add to the resemblance to the last-named disease. The 
features, in consequence of the tumefaction, vesiculation, and papulation, 
may be so swollen as to present a conspicuous deformity ; and the fore- 
arms, and even the arms, seem greatly increased in size from the same 
cause. The feet and legs also may, in the unconsciousness of sleep, be 
exposed in hot weather to the depredations of these marauders, and in 
the same way the back, the buttocks, and, rarely, even the genitalia may 
present the same signs of inflammation. The matter of chief moment 
is the correct diagnosis of such cases, as many patients seeking relief under 
such circumstances have been treated for disorders with which they 
were not affected. 






PROTOZOA AND SPOROZOA. 913 



PROTOZOA AND SPOROZOA. 

The relations sustained by some forms of protozoa to diseases of the 
skin and of other organs in man are as yet undetermined. The so-called 
psorosperms observed by a number of investigators in Darier's disease, 
carcinoma, molluscum fibrosum, Paget's disease, herpes zoster, and 
varicella have been demonstrated clearly to be bodies produced by cell- 
transformation. 1 It is well known, however, that the livers and other 
organs of rabbits and of some other animals often contain coccidise (a 
subclass of sporozoa), and several instances of peculiar forms of disease 
in man have been reported in which protozoa were satisfactorily demon- 
strated. Psorospermosis of internal organs of man is described by 
Osier 2 and by Blanchard. 3 

Protozoan and coccidoidal infections of the skin are considered with 
cutaneous blastomycosis (page 881). 

1 Of. Gilchrist, Johns Hopkins Hospital Keports, i., 1896; and Second Annual 
Keport of the Cancer Committee of the Harvard Medical School, Jour. Med. Kesch., 
1902, vii., No. 3. 

2 Principles and Practice of Medicine, p. 1080, p. 682. New York, 1895. 

3 Bouchard's Traite de Pathologie generale, tome ii., p. 682. Paris, 1896. 

58 



INDEX 



ABKUS precatorius, 109 
Acanthia lectularia, 911 

Acantholysis bullosa, 479 
Acanthoma, 522 
Acanthosis, 72 
nigricans, 526 

etiology, 526 

pathology, 526 
Acare des follicules, 892 
Acari transmitted from men to animals, 910 
Acarus folliculorum, 155, 892 

scabiei, 882 
Achroma, 565 
Achromia, 563 

congenital, 564 
unguium, 599 
Acid mixture, Startin's, 446 
Acne, 439 

diagnosis, 444 

etiology, 443 

pathology, 444 

prognosis, 453 

symptoms, 440 

treatment, 445 
albida, 158 
artificialis, 440 
atrophica, 439, 440 
cachecticorum, 441 
contagious, 443 
disseminata, 442 
frontalis, 459 
hypertrophica, 440 
indurata, 441 
-keloid, 442, 615 
keratosa, 442 
necrotica, 459 
papulosa, 441 
parasitica, 442 
punctata, 441 
pustulosa, 442 
rodens, 459 
rosacea, 453 

diagnosis, 455 

etiology, 454 

pathology, 455 

prognosis, 458 

symptoms, 453 

treatment; 456 
sebacea, 140 
tar-, 326 
urtieata, 443 
varioliformis, 459 

diagnosis, 460 

etiology, 460 

pathology, 460 



Acne varioliformis, prognosis, 460 
symptoms, 460 
treatment, 460 
vulgaris, 439, 442 
Acne, 439 

cancroidale, 631 
comedon, 153 
decalvante, 585 
keloidienne, 589 
miliaire, 158 
ponctuee, 153 
rosee, 453 
sebacee cornee, 498 

fluente, 140 
varioliforme, 459, 506 
Acnitis, etc., 681 
Acrochordon, 618 
Acrodermatitis chronica atrophicans, 602 

perstans, 435 
Acrodermites continues, 435 
Acrodynia, 209 
diagnosis, 211 
etiology, 210 
pathology, 211 
prognosis, 211 
symptoms, 209 
treatment, 211 
Acromegaly, 561 
diagnosis, 562 
etiology, 562 
pathology, 562 
prognosis, 562 
symptoms, 561 
treatment, 562 
Actinomycose, 870 
Actinomycosis of skin, 870 
diagnosis, 872 
etiology, 871 
pathology, 871 
prognosis, 872 
symptoms, 870 
treatment, 872 
Acute circumscribed oedema, 226 
idiopathic oedema, 226 
non-inflammatory oedema, 226 
purulent oedema, 274 
tuberculosis of skin, 661 
Addison's disease, 489 
Adenoma, acquired benign, 631 
of coil-glands, 632 
diagnosis, 632 
treatment, 632 
congenital benign, 631 
malignant, 63 L 
diagnosis, 632 

915 



916 



INDEX. 



Adenoma, malignant, etiology, 631 
pathology, 632 
symptoms, 631 
treatment, 632 
of sebaceous glands, 633 
sebaceum, 631 
of sweat-glands, 633 
Adenomes cancro'ideux, 631 

sebaces, 631 
Aden ulcer, 272 
Afghan plague, 269 
Age, 65 
Ainhum, 608 

diagnosis, 610 
etiology, 609 
pathology, 609 
symptoms, 608 
treatment, 610 
Akne, 439 
Aktinomykose, 870 
Albinism, 563, 564 

partial, 563 
Albinism us, 564 
etiology, 564 
symptoms, 564 
Albinoes, 564 
Albugo, 599 
Aleppo evil, 269 
Alibert's keloid, 613 
Alkalies, 93 
Alligator-skin, 528 
Alopecia, 570 

etiology, 574 
pathology, 574 
prognosis, 576 
symptoms, 570 
treatment, 574 
areata, 576 

diagnosis, 582 
etiology, 579 
pathology, 581 
prognosis, 585 
symptoms, 576 
treatment, 582 
cicatrisata, 585 
circumscripta, 576, 580 
congenital, 570 
false, 586 
follicularis, 585 
etiology, 587 
pathology, 587 
prognosis, 588 
symptoms, 585 
treatment, 588 
furfuracea, 573 
orbicularis, 579 
pityrodes capillitii, 573 
premature, 572 
presenile, 572 
senile, 571 

symptomatic presenile, 573 
Alopecie, 570 

cicatrieielle innominee, 585 
Alphos, 308 

Amblyomma Americanus, 901 
Anaemia, 71 



Anaesthesia, 808 

Analgesic paralysis, with whitlow, 607 

Analgesics, 95 

Anatomical tubercle, 658 

Anatomy of the skin, 17 

Anderson's, McCall, ointment, 100 

powder, 202 
Anginose scarlatina, 173 
Angiokeratoma, 503 
etiology, 503 
pathology, 504 
prognosis, 504 
symptoms, 503 
treatment, 504 
Angioma, 638 

diagnosis, 641 
etiology, 641 
pathology, 641 
prognosis, 643 
symptoms, 638 
treatment, 641 
cavern osum, 640 
infective, 643 

pigmentosum et atrophicum, 647 
serpiginosum, 643 
diagnosis, 644 
etiology, 644 
pathology, 644 
symptoms, 643 
treatment, 644 
Angiorne cystique, 645 
Angiomyoma, 637 
Angioneurotic oedema, 226 
diagnosis, 227 
etiology, 226 
pathology, 226 
symptoms, 226 
treatment, 227 
Anhidrosis, 133 
Anidrose, 133 
Anidrosis, 133 

treatment, 134 
Animal extracts, 95 
parasites, 881 
poisons, 268 
Anomalous discoloration of skin and mu- 
cous membranes, 49 
Anthemata, 61 
Anthrarobin, 109 
Anthrax, 264 

diagnosis, 265 
etiology, 265 
pathology, 265 
prognosis, 266 
simplex, 261 
symptoms, 264 
treatment, 266 
Anthrax, 261 
Antimony, 95 
Apes m ell if era?, 912 
Area Celsi, 576 

Johnstoni, 576 
Argyria, 490 
Arrectores pilorum, 36 
Arsenic, 91 
Arthritic purpura, 483 



INDEX. 



917 



Arthrodynia, 209 
Arzneiexa n th em e, 235 
Asiatic pill, 92 
Asphyxia, local, 251 
Asteatose, 152 
Asteatosis, 152 

pathology, 152 
prognosis, 153 
symptoms, 152 
treatment, 153 
Athrepsie, 514, 546 
Atrophia cutis, 600 

universalis, 602 
maculosa et striata, 601 
etiology, 603 
pathology, 603 
symptoms, 601 
treatment, 603 
pilorum propria, 591 
senilis, 600 
unguis, 598 

treatment, 599 
Atrophic spots, 607 
Atrophies, 563 

Atrophoderma pigmentosum, 647 
senile, 600 

striatum et maculatum, 601 
Atrophodermia neurotica, 603 
Atrophy of skin, 73, 600 
blanching, 604 
idiopathic diffuse, 602 
general, 602 
partial, 601 
progressive, 602 
Ausssatz, 753 
Autogram, urticarial, 215 
Auto-infection, 66 

BACILLOGENOUS sycosis, 275 
Bacteria, 71 
Bacterium fcetiduin, 135 
" Bad disorder," 693 
Baldness, 570 
Balggeschwulst, 161 
Barbadoes leg, 555 
Barbers' itch, 275, 848 
Bartfinne, 275 
Bartflechte, 275 
Basal layer, 27 
Bassorin paste, 104 
Bastard measles, 169 
Baths, 97 

antiseptic, 99 

marine, 99 

salt, 99 

sulphur, 98 

tar, 99 
Becquerel rays, 121 
Bed-bugs, 91 i 
Bed-hairs, 37 
Beigel's disease, 598 
Bettwanze, 911 
Biskra Bouton, 269 
" Black-heads," 153 
Black fever, 211 

small-pox, 180 



Bldschenjiechte, 291 
Blasenausschlag, 462 
Blastomycetic dermatitis, 873 
Blastomycosis, 873 

diagnosis, 880 

etiology, 876 

pathology, 877 

prognosis, 880 

symptoms, 874 

treatment, 880 
Blattern, 176 
Blebs, 57 

Bleeding stigmata, 139 
Blood-vessels, 29 
Bloody sweat, 139 
Blue disease, 211 
Blutgeschivdr, 258 
Boba, 769 
Bodv-louse, 905 
Boil* Bucharest, 271 

Delhi, 269 
Boils, 258 
Boric acid, 108 
Boquet, 209 
Bou-bou, 209 
Bouton $ Amboine, 769 

d' Orient, 269 
Bowditch Island ringworm, 854 
Brandschwdr, 261 
" Brandy-nose," 453 
Bromhidrosis, 134 
Bromidrose. 134 
Bromidrosis, 134 

etiology, 135 

pathology, 135 

symptoms, 134 

treatment, 135 
Bubas, 769 
Buccal psoriasis, 634 
Bucharest boil, 271 
Bucnemia tropica, 555 
Bug, harvest-, 898 
Bugs, 911 
Bulb of hair, 40 
Bulb- corpuscles, 35 
Bulkley's alkaline tar solution, 399 
Bulla?, 57 

hemorrhagica?, 482 
Bullous eruption following vaccination, 192 

peculiar, 302 
Burmese ringworm, 854 
Burns, 232 
Bursa? mucosa?, 20 
Button, Gafsa, 269 

oriental, 269 

CACHEXIA strumipriva, 819 
thyroidea, 819 

Cachexie pachydermique, 819 
Callositas, 510 

of hands, with unusual complications 
511 

symptoms, 510 
Calvities, 570 

premature, 572 
Calx sulphurata, 94 



918 



INDEX. 



Cancer, 786 

epithelial, 786 

fibrous, 800 

hard, 800 

lenticular, 800 

of connective tissue, 800 

of extremities, 791 

of genital organs, 791 

of head, 790 

of lip, 791 

of mucous membranes, 791 

scirrhous, 800 

" spider," 639 
Cancer en cuirasse, 801 
Cancro'ide, 613, 786 
Cancroid ulcer, 787 
Canities, 568 

etiology, 569 

pathology, 569 

symptoms, 568 

treatment, 569 
Canker rash, 171 
Carathe, 863 
Carbolic acid, 75, 108 
Carbuncle, 261 

splenic fever, 264 
Carbunculus, 261 

diagnosis, 263 

etiology, 262 

pathology, 262 

prognosis, 264 

symptoms, 261 

treatment, 260 
Carcinoma, 786 

epithelial, 786 

melanotic, 802 

pigmented, 802 

tuberose, 802 
Carrion's disease, 771 
Cascadoe, 854 
Cathartics, 93 
Cativi, 863 
Causes of skin disease, external, 67 

internal, 64 
Cells, giant, 75 

Langerhans, 27 

mast-, 74, 75 

pathological, corium, 74 

plasma, 74 

plate-, 74 

touch-, 34 
Cellulome epitheliale eruptif kystique, 633 
Cement substance, 22 
Chafing, 200 
Chalazion, 162 
Chalazodermia, 619 
Chancre, non-infecting, 750 

simple, 750 

soft, 750 
Chancre du Sahara, 269 
Chancrelle, 750 
Chancroid, 750 

diagnosis, 753 

pathology, 753 

treatment, 754 
" Chapping," 364 



"Chaps," 364 

Charbon, 264 

Cheilitis exfoliativa, 409 

glandularis aposthematosa, 409 
Cheiro-pompholyx, 306 
Cheloid, 613 
Cheloide, 613 
Chigoe, 892 
Chicken-pox, 186 
Chignon fungus, 598 
Chilblains, 199, 234 
Chinese ringworm, 854 
Chloasma, 488, 856 

diagnosis, 492 
pathology, 491 
prognosis, 493 
symptoms, 488 
treatment, 492 
. cachecticorum, 489 

from ingestion of arsenic, 490 

uterinum, 489 
Chloral-camphor, 110 
Chorionitis, 547 
Chromidrosis, 136 

etiology, 137 

pathology, 137 

treatment, 138 
Chromocrinia, 137 
Chrysarobin, 94, 109 
Cicatrice, 611 
Cicatrices, 60 
Cicatricial keloid, 613 
Cicatrix, 611 

diagnosis, 612 

etiology, 612 

pathology, 612 

prognosis, 616 

symptoms, 611 

treatment, 612 
Cimex lectularius, 911 
diagnosis, 911 
treatment, 912 
Class I., 125 

IL, 165 

III., 481 

IV., 487 

V., 563 

VI., 611 

VII., 805 

VIIL, 823 
Classification, American Dermatological 
Association, 123 

Anspitz, 122 

Hebra, 123 
Clastothrix, 593 
Clavus, 511 

histology, 512 

symptoms, 511 

treatment, 512 
Cleavage of skin, 22 
Climate, 68 
Clothing, 69 
Clou, 258 

Clou de Biskra, 269 
Coccidioidal infection of skin, 881 
Coccogenous sycosis, 275 






INDEX. 



919 



Cochin China ulcer, 272 

leg, 555 
Coco, 769 
Cod-liver oil, 93 
Coil of coil-glands, 44 
Coil-duct, cysts of, 131 
Coil-glands, 44 
" Cold abscess of skin," 662 
" Cold-sores," 291 
Collodion, 106 

Colloid metamorphosis of skin, 630 
diagnosis, 630 
etiology, 630 
pathology, 630 
treatment, 630 
Columnar adiposae, 21 
Columns, fat, 21 
Comedo, 153 

diagnosis, 156 

etiology, 154 

pathology, 155 

prognosis, 158 

symptoms, 153 

treatment, 156 

tedones in chile 

in groups, 154 

scar-, 154 
Condyloma, 710, 723 

acuminatum, 515 
Condylomatosis, 469 

pemphigoida maligna, 469 
Cones fib reux, 21 
Confluent variola, 181 
Congelatio, 234 
Congenital alopecia, 570 

fibrosebaceous disease, 163 

keratosis of palms and soles, 501 
Conglomerative pustular perifolliculitis, 
290 

etiology, 290 

pathology, 290 

treatment, 291 
Constitutional disorders, 65 
Contagion, 69 
" Coolie-itch," 897 
Copaiba, 95 
" Copper-nose," 453 
Cor^ 511 
Corium, 21 

cells, pathological, 74 

structure, cellular, 73 
fibrous, 73 
Corn, 511 

Come de la peau, 513 
Cornu cutaneum, 513 
etiology, 514 
pathology, 514 
prognosis, 515 
symptoms, 513 
treatment, 515 

humanum, 513 
Corpuscles, bulb, 35 

of Krause, 35 

of Meissner, 33 

of Vater, 32 

of Wagner, 33 



Corpuscles, Pacinian, 32 

tactile, 33 
Cosme's paste, 797 
Counter-irritation, 111 
Couperose,4:03 
Cow-pox, 188 
Crab-louse, 908 
" Crab-yaws," 770 
Crapeaux, 770 
" Crateriform ulcer," 788 
Craw-craw, 896 

etiologv, 897 

prognosis, 897 

treatment, 897 
Creosote, 95 
Cretinoid oedema, 819 
Crustse, 58 
Crusts, 58 
Culex pipiens, 912 
Cutaneous tumors, multiple, with pruritus, 

521 
Cuterebra, 901 
Cuticle, 25 
Cuticula, 25 
Cutis, 21 

testacea, 144 

vera, 21 
Cyanhidrosis, 137 
Cyst, sebaceous, 161 
Cystadenomes epithelieux benins, 633 
Cystic disease, sebaceous, 16.3 

lymphangioma, 645 
Cysticercus cellulosae cutis, 897 

diagnosis, 898 
Cysts, 161 

fat, 161 
of the coil-ducts, 131 

DANDKUFF, 140 
Darier's disease, 498 
Dartre, 291 

humide, 282 
Deciduous skin, 198 
Decolorization des ongles, 399 
Defluvium capillorum, 570-573 
Degeneration of skin, colloid, 76 
crenation, 76 
fatty, 75 

myxomatous, 76 
mucoid, 76 
cedematous, 76 
Delhi boil, 269 
Demodex folliculorum, 892 
Dengue fever, 209 
Derma, 21 
Dermanyssus avium, 910 

gallinse, 96 
Dermatalgia, 806 
diagnosis, 807 
treatment, 807 
Dermatite, 228 

exfoliativa, 332 
Dermatitis, 228 

blastomvcotica, 873 
bullous, 467 
calorica, 232 



920 



INDEX. 



Dermatitis calorica, treatment, 233 
contusiformis, 205 
exfoliative, 332 
diagnosis, 334 
etiology, 333 
pathology, 334 
prognosis, 334 
symptoms, 334 
treatment, 334 
gangrenosa, 248 

infantum, 249 
herpetiformis, 302 
diagnosis, 303 
etiology, 304 
pathology, 304 
prognosis, 306 
symptoms, 302 
treatment, 305 
medicamentosa, 66, 235 
diagnosis, 245 
symptoms, 235 
neonatorum, 335 
prognosis, 335 
treatment, 335 
papillaris capillitii, 589 
psoriasiformis nodularis, 344 
repens, 434 

scarlatiniformis recidiyus, 197 
seborrheica, 428 
traumatica, 228 
variegata, 344 
vegetans, 471 
venenata, 228 

diagnosis, 231 
etiology, 229 
symptoms, 228 
treatment, 231 
x-ray, 247 

treatment, 247 
Dermatobia noxalis, 901 
Dermatolysis, 619 
Dermatomycosis furfuracea, 856 
Dermatosclerosis, 547 
Dermatosis probably tubercular, 676 
Kaposi, 647 
ciat( 

diagnosis, 679 
etiology, 682 
pathology, 681 
symptoms, 680 
treatment, 682 
Dermite, 228 
Dermographism, 215 
De Valan gin's solution, 92 
Depilatories, 544 
Dhobie itch, 856 

treatment, 856 
Diabetides, 365 
Diachylon salve, Hebra, 392 
Diagnosis, general, 77 
Diet in eczema, 380 
Dipterous larva? in the skin, 900 
Discoid trichophytic erythema, 835 
Diseases due to animal parasites, 881 

due to vegetable parasites, 823 
Disorders of glands, 125 



Disorders of sebaceous glands, 140 

of sweat-glands, 125 
Dissection-tubercle, 658 
Dissection-wounds, 268 
Distoma hepaticum, 898 
Diuretics, 93 
Dondas, 564 
Donovan's solution, 92 
Dracontiasis, 894 

diagnosis, 895 

etiology, 895 

pathology, 895 

prognosis, 896 

symptoms, 894 

treatment, 895 
Dracunculus Medinensis, 894 
Dragonneau, 894 
Drug eruptions, 235 
Duhring's disease, 302 

modified Asiatic pill, 92 
Dyes, 570 
Dysidrose, 306 
Dysidrosis, 306 

ECCHYMOMATA, 482 
Ecchymoses, 482 
Echinococcus, 898 
Ecthyma, 287 

diagnosis, 289 

etiology, 288 

pathology, 288 

prognosis, 290 

symptoms, 289 

treatment, 289 
gangrenous infantile, 249 
Ecthyma terebrant, 249 
Eczem, 356 
Eczema, 356 

diagnosis, 373 

etiology, 367 

pathology, 371 

prognosis, 402 

symptoms, 356 

treatment, 380 
acute, 366 
ani, 417 
aurium, 411 
barbae, 413 
capillitii, 404 
capitis, 404 
chemic, 366 
crurale, 421 
crurum, 421 
diabeticorum, 365 
diet in, 380 
erythematosum, 358 
exfoliativum, 359, 363 
faciei, 406 
fissum, 363 
folliculorum, 365 
genital, 414 
genitalium, 414 
impetiginodes, 362 
intertrigo, 200, 364 
labiorum, 408 
lichenodes, 359 






INDEX. 



921 



Eczema madidans, 363 

mammae, 419 

manuum, 422 

marginatum, 366, 835 

narium, 410 

of anus, 417 

of beard, 413 

of breast, 419 

of children, 403 

of ears, 411 

of eyelids, 412 

of face, 406 

of feet, 422 

of hands, 422 

of lips, 408 

of nails, 426 

of nipple, 419 

of nostrils, 410 

of nurslings, 365 

of palms, 423 

of scalp, 404 

of soles, 423 

of trades, 423 

of tropics, 427 

of umbilicus, 420 

palpebrarum, 412 

papulosum, 359 

parasiticum, 365 

pedum, 422 

pustulosum, 362 

rhagadiforme, 362 
■ rubrum, 363 

sclerosum, 364 

seborrhoeicum, 366, 428 
diagnosis, 433 
etiology, 431 
pathology, 432 
symptoms, 429 
treatment, 434 

solare, 427 

squamosum, 359, 363 

tuberculatum, 773 

tuberculous, 682 

umbilici, 420 

unguium, 426 

universale, 426 

verrucosum, 357, 364 

vesiculosum, 360 
Eczema, 356 

craquele, 364 
" Egg-foot," 865 
Eiterbeule, 258 
Eiterblase, 287 
Eiterflechte, 282 
Eitergeschwar, 258 
Ekthyma, 287 
Electrolysis, 111 

in removal of superfluous hairs, 540 
Elei'din, 28 
Elephant foot, 865 

leg, 555 
Elephantiasis, 555 

diagnosis, 559 
etiology, 557 
pathology, 559 
prognosis, 561 



Elephantiasis, symptoms, 555 
treatment, 560 
Arabum, 555 
Grsecorum, 755 
lymphangiectatica, 645 
nsevoid, 557 
tuberculosa cutis, 660 
Elliott's Bassorin paste, 104 
Endemic degeneration of bones of foot, 865 
Endemische JBevleiikraiikheit, 269 
Endothelioma of skin, 803 
Engelure, 199 
Ephelide, 487 
Ephelis, 487 
Ephidrosis, 125 
tincta, 136 
Epidemic exfoliative dermatitis, 342 
etiology, 343 
herpetic fever, 292 
roseola, 169 
skin disease, 342 
Epidermis, 25 

Epidermolysis bullosa hereditaria, 479 
Epithelial cancer, 786 

degeneration, 73 
Epithelialkrebs, 786 
Epithelioma, 786 

diagnosis, 794 
etiology, 792 
pathology, 793 
prognosis, 798 
symptoms, 786 
treatment, 795 
adenoides cysticum, 633 
contagiosum, 506 
deep, 787 
discoid, 787 
papillary, 789 
superficial, 787 
tubercular, 788 
Epitheliomatose pigmentaire, 647 
Epitrichial layer, 29 
Equinia, 266 

etiology, 267 
pathology, 267 
prognosis, 268 
symptoms, 266 
treatment, 268 
Erbgrind, 823 
Erectores pilorum, 36 
Ergot, 94 
Ergotine, 94 
Erntemilbe, 898 
Eruptions, feigned, 246 
Eruptions medicamenteuses, 235 
Erysipel, 252 
Erysipelas, 252 

diagnosis, 253 
etiology, 254 
pathology, 254 
prognosis, 256 
symptoms, 252 
treatment, 250 
ambulans, 253 
chemic, 254 
chemicum, 257 



922 



INDEX. 



Erysipelas, Lombardy, 213 
Erysipele, 252 
Erysipeloid, 257 

treatment, 257 
Ery.thanthema syphiliticum, 722 
Erythanthemata, 61 
Erythema, 193 

diagnosis, 195 

symptoms, 197 

treatment, 195 
ab igne, 194 
annulare, 204 
bullosum, 204 

vegetans, 469 
caloricum, 194 
circinatum, 204 

desquamative scarlatiniform, 197 
discoid trichophytic, 835 
elevatum diutinum, 212 
figuratum, 204 
fugax, 195 
gangrenosum, 195 
hypersemicum, 193 
induratum, 204, 678 

diagnosis, 678 

etiology, 678 

pathology, 678 

symptoms, 678 

treatment, 679 
intertrigo, 200 

diagnosis, 201 

etiology, 201 

symptoms, 200 

treatment, 202 
iris, 204 
lseve, 195 
leprosum, 759 
marginatum, 204 
migrans, 257 
multiforme, 203 

diagnosis, 208 

etiology, 206 

pathology, 207 

prognosis, 209 

symptoms, 203 

treatment, 208 
nodosum, 205 
nummular, 835 
papulatum, 204 
papulosum, 204 
paratrimma, 195 
pernio, 199 

diagnosis, 199 

treatment, 200 
punctatum, 197 
scarlatiniforme, 197 

diagnosis, 198 

etiology, 198 

prognosis, 198 

symptoms, 197 

treatment, 198 
scarlatinoid, 198 
• simplex, 193 
solare, 194 
symptomatic, 195 
traumaticum, 194 



Erythema tuberculatum, 204 

tuberculosum, 204 

urticatum, 204 

variolous, 176 

venenatum, 195 

vesicolosum, 204 
Erythematous syphilide, 702 
Erytheme, 193 

centrifuge, 683 

indure des scrofuleux, 678 

noueux, 205 

scarlatiniforme desquamatif, 197 

scarlatino'ide, 197 
Erythrasma, 860 

diagnosis, 862 

etiology, 861 

pathology, 862 

symptoms, 861 

treatment, 862 
Erythrodermie exfoliante, 332 

pityriasique en plaques disseminees, 344 
Erythromelalgia, 807 
Esthiomene, 658 
Etiology, general, 64 
Exanthemata, 61, 165 
Exanthematic miliary tuberculosis of skin, 

661 
Excoriations, 58 

neurotic, 139 
Exfoliative inflammation of lips, 409 

FARCIN, 266 

Farcy, 266 
Fat-columns, 21, 47 
Fatty substances, 100 
Favic onychomycosis, 825 
Favus, 823 

of nails, 825 
Feigned eruption, 246 
Feigwarze, 515, 723 
Fetid sweat, 134 
Fettsklerem, 546 
Fever, black, 211 

Rockv Mountain, 211 

spotted, 211 

tick, 211 

vaccinal, eruptive, 192 
Fibres of Herxheimer, 25 

nerves, medullated, 31 
non-medullated, 31 

spiral, 25 
Fibroblasts, 74 

" Fibroid of skin, recurrent," 782 
Fibrom, 617 
Fibroma, 617 

diagnosis, 620 
etiology, 619 
pathology, 620 
prognosis, 620 
symptoms, 617 
treatment, 620 

fungoides, 773 

molluscum, 617 

pendulum, 619 

simplex, 618 
Fibromatosis tuberculosa cutis, 660 



INDEX. 



923 



Fibromyoma, 637 

Fibrosebaceous disease, congenital, 163 

Ficosis, 275 

Fig-wart, 515 

Filaria dracunculus, 894 

medinensis, 894 

nocturna, 557 

sanguinis bominis, 557 
Filth, 69 

Finger-nail filth, 285 
Finsen-light, lamps, 120 

treatment, 117 
Finsen red-light treatment of small-pox, 185 
Fischschuppenausschlag, 527 
Fish-oil, 107 
Fish-skin disease, 527 
Fissures, 59 
" Flannel-rash," 431 
Flea, 893 
Flechte, 291 
Flecken„ 165 
Fleckenmal, 523 
Follicles, hair, 37 
Follielis, 681 
Folliculite cicatricielle necrotique, , 459 

epilante, 585 

et perifolliculite decalvantes, 585 

destructif du follicule pileux, 585 
Folliculitis, 290 

agminate, 835 

barbae, 275 

conglomerate, 835 

decalvans, 588 

varioliformis, 439 
Food as a cause of disease of the skin, 66 
Formaldehyde, 109 
Formalin, 109 
Fowler's solution, 92 
Fragilitas crinium, 592 
treatment, 592 
Framboesia, 769 

diagnosis, 771 

etiology, 771 

pathology, 771 

prognosis, 771 

symptoms, 770 

treatment, 771 
Framose, 769 
Freckles, 487 
Freezing, 234 
French measles, 169 
Friesel, 129 
Frostbeule, 199 
Frost-itch, 817 
Fumigation, 741 
Fungus disease of India, 865 

foot of India, 865 
Furoncle, 258 
Furunculus, 258 

diagnosis, 259 

etiology, 259 

pathology, 259 

prognosis, 261 

symptoms, 258 

treatment, 260 
Furunkel, 258 



GAFSA BUTTON, 269 
Galactidrosis, 139 
Gale, 882 
Gangrene, diabetic, 249 

of extremities, symmetrical, 251 
etiology, 257 
pathology, 257 
prognosis, 257 
treatment, 257 

multiple, disseminated, of infants, 249 

of skin, multiple, 248 
Gangrene foudroyante, 274 
Gangrenous infantile ecthyma, 249 
Gastrophilus, 901 
Gefassmal, 638 
Gemeiner floh, 893 
General diagnosis, 77 

etiology, 64 

pathology, 71 

prognosis, 87 

symptomatology, 52 

therapeutics, 89 
German measles, 169 
Giant urticaria, 226 

wheals, 55, 215 
Giant-cells, 75 
Glanders, 266 
Glands, coil-, 44 

diseases of, 125 

Meibomian, 43 

sebaceous, 42 

diseases of, 140 
hypertrophy of, 160 

sweat-, 44 

diseases of, 125 

Tysonian, 43 
Glandulse ceruminosae, 43 

glomiformes, 44 
" Glossy skin," 603 
Glycerin, 101 
Glycogelatin, 104, 395 
Glycosuric xanthoma, 628 
Gogo, 854 
Gormnes scrofuleuses, 662 

scrofolo-tuberculeuses, 662 
Granular layer, 27 
Granuloma, 74 

fungoides, 773 

inguinal tropicum, 271 

perforating, of thigh, 271 

sarcomatodes, 773 

sclerotizing pudenda, 271 
Granulosis rubra nasi, 133 

treatment, 133 
Grayness of hair, 568 
Groin-ulceration, 271 
Grutum, 158 
Griitzbeutel, 161 
Guaiacol, 95 

Guinea-worm disease, 894 
Guineesche Draake, 894 
Gune, 854 

Giirtelausschlag, 295 
Gurtelflechte, 295 
Gutartiges epithelioma, 633 
Gutta rosea, 453 



924 



INDEX. 



JJA A BSA CKMILBE, 892 

Haematidrosis, 139 
treatment, 139 
Haemophilia, 485 
Hair, atrophy of, 591 

cortex of, 41 

deficiency of, 570 

grayness of, 568 

medulla of, 41 

nodose dwellings of, 595 

whiteness of, 568 
Hair-bulb, 40 
Hair-cone, 37 
Hair-dyes, 570 
Hair-follicles, 37 
Hair-root, 40 
Hair-sacs, 37 
Hair-shaft, 41 
Hairiness, 537 
Hairs, 37 

bed, 37 

expansion of, 595 

fissures of, 595 
Harlequin foetus, 530 
Harnschweiss, 138 
Harvest-bug, 898 
Hautentzundung, 228 
Hautfinne, 439 
Hauthorn, 513 
Hautrothe, 193 
Hautsclerem,, 547 
Head-louse, 902 
Hebra's spiritus saponis alkalinus, 99 

ungt. diachyli albi, 392 
Hefenmykose, 873 
Helmerich's salve, 891 
Hemiatrophia facialis, 550 
Hemidrosis, 139 
Hemizona, 295 
Hemorrhages, 481 
Hemorrhagic variola, 180 
Heredity, 64 
Herpes circinatus bullosus, 302 

desquamans, 854 

facialis, 291 

febrilis, 291 

generalized, 292 

genitalis, 292 

gestationis, 302, 304 

iris, 204, 302 

labialis, 291 

menstrualis, 293 

phlyctaenoides, 302 

prseputialis, 292 

progenitalis, 292 

pyaemicus, 461 

simplex, 29 

pathology, 294 
symptoms, 291 
treatment, 294 

tonsurans, 833, 840 
maculosus, 329 

vegetans, 469 

zoster, 295 

diagnosis, 300 
etiology, 298 



Herpes zoster, pathology, 298 
prognosis, 301 
symptoms, 295 
treatment, 300 
Herpes circine, 833 

tonsurans desquamatif, 854 
Hide-bound skin, 547 
Hidrocystoma, 131 
Hirsuties, 537 
Histology of skin, 72 
Hives, 215 
Hoariness, 568 
Holzbock, 901 

" Honeycomb ringworm," 823 
Horn, cutaneous, 513 
Hornauswuchs, 513 
Horny layer, 28 
Huhnerauge, 511 
Hybrid measles, 169 
Hydradenem.es eruptifs, 633 
Hydroa, 302 

aestivale, 278 
herpetiformis, 302 
puerorum, 417 
vacciniforme, 477 
diagnosis, 479 
etiology, 478 
pathology, 478 
prognosis, 479 
symptoms, 477 
treatment, 479 
Hydroa bulleuoc, 304 
vesiculeuz, 204 
Hydrocystoma, 131 
diagnosis, 132 
etiology, 132 
pathology, 132 
symptoms, 132 
treatment, 132 
Hydrosis, 125 
Hyperaemia, 71 
Hyperesthesia, 805 
Hyperalgesia, 806 
Hyperhidrosis, 125 
Hyperidrose, 125 
Hyperidrosis, 125 

etiology, 126 
pathology, 127 
prognosis, 129 
symptoms, 125 
treatment, 127 
oleosa, 140, 145 
Hyperkeratose figuree centrifuge atrophiante, 

505 
Hyperkeratosis, 72 
excentrica, 505 
striata et f ollicularis, 504 
Hypersarcosis, 555 
Hypertrichiasis, 537 
Hypertrichosis, 537 
etiology, 539 
symptoms, 537 
treatment, 540 
neurotica, 539 
Hypertrophic cicatrix, 615 
scar, 615 



INDEX. 



925 



Hypertrophies, 487 
Hypertrophy of hair, 537 

of nail, 534 
Hyphogenous sycosis, 848 
Hypoderma, 901 
Hypodermatic injections, 96 
Hysterical neuroses, 66 

TCHTHYOL, 95, 107 
1 Ichthyose, 527 
Ichthyosis, 527 

diagnosis 533 
etiology, 531 
pathology, 532 
prognosis, 534 
symptoms, 527 
treatment, 533 
congenital, 530 
cornea, 523 
follicularis, 498 
hystrix, 529 

linearis neuropathica, 523 
lingua-, 530, 634 
palmaris et plantaris, 501 
sebacea, 144 

cornea, 498 
simplex, 527 
Idiopathic multiple pigment-sarcoma, 782 
Idrosis, 128 
Ignis sacer, 295 
Impetigo, 282 

diagnosis, 286 
etiology, 285 
pathology, 285 
symptoms, 282 
treatment, 287 
contagiosa, 284 

bullosa, 284 
eczematodes, 362 
herpetiformis, 46 
diagnosis, 462 
etiology, 461 
pathology, 461 
prognosis, 462 
symptoms, 461 
treatment, 462 
strepto-coccogenita circinata, 286 
Impetigo, 282 
India ringworm, 854 
Infection, 69 
Inflammations, 71, 165 
Inflammatory fungoid neoplasm, 773 
Ingesta, 66 

Internal treatment, 91 
Intertrigo, 200 
Intracutaneous injections, 96 
Inunction, 740 
Iodine, 109 

and compounds, 93 
Iron, 95 

Irritation, chemical, 69 
mechanical, 69 
medicinal, 69 
Itch, the, 882 

barber's, 275, 848 
Coolie, 897 



Itch, Dhobie, 856 

frost, 817 

lumberman's, 818 

swamp, 818 
Ittiosi, 527 
Ivy poisoning, 230 
Ixodes, 901 

ricinus, 901 

unipunctatus, 901 

JABORANDI, 95 
Jacob's ulcer, 487 
Jequirity, 109 
Jigger, 892 

JfAHLHEIT, 570 

Kakerlaken, 564 
Karbunkel, 261 
Keloid, 613 

diagnosis, 616 
etiology, 615 
pathology, 615 
prognosis, 616 
symptoms, 613 
treatment, 616 
cicatricial, 615 
of Addison, 549 
of Alibert, 613 
Keloid-acne, 442 

treatment, 590 
Keratodermia excentrica, 505 
palmaris et plantaris, 501 
diagnosis, 502 
etiology, *502 
prognosis, 502 
symptoms, 501 
treatment, 502 
Keratohyalin, 28 
Keratolysis, 198 
Keratosis, 494 

follicularis, 498 

diagnosis, 500 
etiology, 499 
pathology, 499 
symptoms, 498 
treatment, 500 
contagiosa, 504 
pigmentosa, 517 
pilaris, 494 

diagnosis, 496 
etiology, 495 
pathology, 495 
symptoms, 494 
treatment, 496 
senilis, 497 

treatment, 498 
universalis congenita, 530 
vegetans, 498 
Kerion Celsi, 847 
Kleinenflechte, 856 
Knockelkoorks, 209 
Knollenkrebs, 613 
Koch's tuberculin, 96 
Kollenkdrpchen, 35 
Koplik's sign, 166 
Kra-kra, 896 



926 



INDEX. 



Krankheiten der Franzosen, 693 
Kratze, 882 
Kraurosis vulvae, 505 
Krause's corpuscles, 35 
Krithoptes monunguiculosus, 900. 
Kro-kro, 896 
Kuhpocken, 188 
Kupferfinne, 453 
Kyste sebacee, 161 

LABIOMYCOSIS, 410 
Ladrerie, 755 
Lafa tokelau, 854 
Land scurvy, 484 
Langerhans' cells, 27 
Lanolin, 106 
La Rosa, 213 
Rose, 252 
Larva migrans, 901 
Lassar's paste, 101 
Lausesucht, 902 
Lax skin, 619 
Layer, basal, 27 
epitrichial, 29 
granular, 27 
Henle's, 39 
horny, 28 
Huxley's, 39 
mucous, 26 
prickle, 26 
Lead-and-opium wash, 388 
Lebbra, 753 
Leichdorn, 511 
Lentigo, 487 

etiology, 487 
pathology, 488 
symptoms, 487 
treatment, 488 
maligna, 647 
Lentille, 487 
Leontiasis, 755 
Lepothrix, 596 

treatment, 596 
Lepra, 308, 755 _ 

diagnosis, 766 
etiology, 763 
pathology, 764 
prognosis, 769 
symptoms, 755 
treatment, 767 
ansesthetica, 760 
Arabum, 755 
fungifera, 769 
Italica, 213 

maculo-ansesthetic, 759 
maculosa, 759 
trophoneurotica,, 760 
tuberosa, 757 
Lepre, 755 
Leprosy, 755 

atrophic, 768 
Lombardy, 213 
nerve, 760 
nodulated, 757 
tegumentary, 757 
tuberculated, 757 



Leprous roseola, 759 
Leptus, 898 

Americanus, 899 
autumnalis, 898 
irritans, 899 
Lesions, consecutive, 57 
elementary, 53 
unclassified, 61 
Leucasmus, 563 
Leucoderma, 563 
acquired, 565 
complete, congenital, 564 
syphiliticum, 705 
Leucokeratosis buccalis, 634 
diagnosis, 636 
etiology, 635 
pathology, 636 
prognosis, 637 
symptoms, 634 
treatment, 636 
Leucoma, 634 
Leucoplasia, 634 
Leucoplasie, 634 
Leukasmus, 565 

congenital, 564 
Leukonychia, 599 
Leukopathia, 565 
congenital, 564 
unguium, 599 
Leukoplakia buccalis, 311, 634 
Lichen annularis, 355 
annulatus, 431 
circumscriptus, 431 
eczematodes, 359 
pilaris, 494 
planus, 348 

diagnosis, 352 
etiology, 352 
pathology, 352 
prognosis, 355 
symptoms, 348 
treatment, 353 
acuminatus, 339, 347 
annularis, 351 
atrophicus, 351 
erythematosus, 351 
hypertrophicus, 349 
linearis, 351 
mamiliformis, 350 
obtusus, 350 
planus, 348 
ruber, 347 
verrucosus, 349 
scrofulosorum, 676 
diagnosis, 677 
etiology, 676 
pathology, 676 
prognosis, 677 
symptoms, 676 
treatment, 677 
scrofulosus, 676 
serpiginosus, 431 
simplex, 359 
syphilitic, 707 
tropicus, 427 
urticatus, 216 



INDEX. 



927 



Lichen variegatus, 344 
Lichenification, 61 
Lichenification, 355 
Lichenoid eruption, 344 
Linear naevus, 523 
Linimentura es 
Linsenmal, 523 
Lioderma essentialis cum melanosi et telan- 
giectasia, 647 
Liquor picis alkalinus, 399 
Livedo, 196 
Local asphyxia, 251 
Lombardy erysipelas 213 

leprosy, 213 
Louse, body, 905 

crab, 908 

head, 902 

pubic, 908 
Lousiness, 902 
Lucilia Caesar, 901 
Lues venerea, 693 
" Lumberman's itch," 818 
" Lumpy-jaw," 870 
Lunula, nail, 50 
Lupani, 769 

Lupoid sycosis, 275, 277, 585, 586 
Lupus crustosus, 655 

disseminatus, 685 

elephantiacus, 654 

elevatus, 654 

endemicus, 269 

erythematodes, 683 

erythematosus, 683 

diagnosis, 688 
etiology, 686 
pathology, 687 
symptoms, 683 
treatment, 689 
livedo form, 686 
telangiectatic form, 685 

exfoliativus, 655 

exuberans, 654 

exulcerans, 655 

fibrosus, 655 

fungoides, 655 

fungosus, 655 

gangrsenosus, 655 

hypertrophicus, 654 

keloides, 655 

lymphaticus, 645 

maculosus, 653 

non-exedens, 654, 683 

non-ulcerosus, 654 

oedematosus, 654 

of ears, 656 

of extremities, 657 

of face, 656 

of genitalia, 657 

of mucous membrane, 637 

of trunk, 657 

papillosus, 654 

pernio, 686 

planus, 653 

profundus, 655 

psoriasiforme, 655 

psoriasis, 655 



Lupus rodens, 655 

rupioides, 655 

sclerosus, 655, 659 

sebaceus, 683 

serpiginosu*, 655 

superficialis, 655, 683 

tuberculatum 654 

tumidus, 654 

vegetans, 655 

verrucosus, 659 

vulgaris, 653 
Lupus demisclereux de la langue, 657 

papillaire verruqueux, 659 

sclereux, 665, 659 
Lustseuche, 693 
Lymph-scrotum, 557 
Lymphadenectasia, 645 
Lymphadenie cutanee, 773 
Lymphangiectasis, 644 
Lymphangiectodes, 645 
Lymphangioma, 644 

cavernosum, 645 

capillare varicosum, 645 

circumscriptum, 645 
etiology, 646 
pathology, 640 
symptoms, 646 
treatment, 647 

cystic, 645 

simple, 645 

tuberosum multiplex, 674 
Lymphangitis tuberculosa cutanea, 664 
Lymphatic vessels, 30 
Lymphangiomyoma, 637 
Lymphodermia perniciosa, 773 

MACULE, 53 
ccerulese, 910 
Macular syphilide, 702 
Madura disease, 865 

foot, 865 
Madumfass, 865 
Maladie de Duhring, 302 

pediculaire, 902 
Mai de Cayenne, 555 

de los Pintos, 863 

perforant du pied, 605 

pintado, 863 

roxo, 213 
Maliasmus, 266 
Malignant pustule, 264 
Malleus, 266 
Maltine, 95 

Malum perforans pedis, 605 
Marsden's paste, 797 
Masern, 165 
Mast-cells, 74, 75 
Matrix of nail, 50 

of roof-sheath, 39 
McCall Anderson's powder, 202 
Measles, 165 

bastard, 169 

French, 169 

German, 169 

hybrid, 169 
Medina worm, 891 






928 



INDEX. 



Medinawurm, 894 
Meibomian glands, 43 
Melanoderma, 488 

cachecticorum, 489 
scrofulosum, 682 
Melanosarcoma, 780 
Melanosis lenticularis progressiva, 647 
Membranes, muscular, 36 
Mentagra, 275 

parasitica, 848 
Mercury, 92, 110 
MerkePs touch-cells, 34 
Microsporon furfur, 858 
Miliaria ciystallina, 129 

rubra, 427 
Miliaire crystalline, 129 

scrofuleuse, 459 
Miliary fever, 131 
Milium, 158 

diagnosis, 159 
etiology, 159 
pathology, 159 
symptoms, 158 
treatment, 160 
congenitalis, 160 
en plaques, 160 
Mihbrand, 264 

karbunkel, 264 
Mineral waters, 96 
Mistura ferri acida, 93 
Mitesser, 153 
Moist wart, 515 
Mole, pigmentary, 523 
Molluscum contagiosum, 506 
epitheliale, 506 
diagnosis, 506 
etiology, 508 
pathology, 508 
prognosis, 510 
symptoms, 506 
treatment, 510 
pendulum, 617 
sebaceum, 506 
verrucosum, 506 
Monilethrix, 595 
etiology, 595 
pathology, 595 
treatment, 595 
Morbilli, 165 
Morbus gallicus, 693 

maculosus Werlhoffii, 484 
pediculosis, 902 
pedis entophyticus, 865 
tuberculosus pedis, 865 
Moroiglione, 186 
Morphoea, 549 
Morpion, 908 
Morvan's disease, 607 
diagnosis, 608 
etiology, 607 
pathology, 608 
symptoms, 607 
treatment, 608 
Morve, 266 
Mountain fever, 211 
Mower's mite, 898 



Mozambique ulcer, 272 
Mucous layer, 26 

patch, vegetating, 710 
patches, 723 
Multiple benign cystic epithelioma, 633 
pathology, 633 
treatment, 634 
disseminated gangrene of infants, 249 
gangrene of the skin, 248 
sarcoid, 783 

tumor-like new-growths, 604 
Muscidse, 901 
Muscles, 36 

Muscular fibres, non-striated, 36 
striated, 36 
membranes, 36 
Mycetoma, 865 
diagnosis, 869 
etiology, 868 
pathology, 868 
symptoms, 866 
treatment, 870 
Mycetome, 865 
Mycosis cutis cutanea, 269 
fungoides, 773 

diagnosis, 778 
etiology, 777 
pathology, 777 
prognosis, 780 
symptoms, 773 
treatment, 779 
eczematous period, 774 
erythematous period, 774 
fungoid period, 775 
infiltration period, 774 
lichenoid period, 774 
mycofungoid period, 775 
neoplastic period, 775 
premycosic period, 774 
microsporina, 856 
Myoma, 637 

diagnosis, 638 
treatment, 638 
dartoic, 637 
telangiectodes, 637 
Myringomycosis, 863 
Myxodermitis labialis, 409 
Myxcedema, 819 
diagnosis, 820 
etiology, 820 
pathology, 820 
symptoms, 819 
treatment, 820 

ffACKENKELOID, 589 
Nsevi pigmentosi, 539 
pilosi, 539 
Nsevoid elephantiasis, 557 
Nsevus araneus, 453, 639 
flammeus, 638 
linea, 523 
lupus, 643 
nervosus, 523 
pigmentosus, 523 
etiology, 524 
pathology, 525 






INDEX. 



929 



Nsevus pigmentosus, prognosis, 525 
symptoms, 523 
treatment, 525 

sanguineus, 638 

spilus, 523 

unius lateris, 523 

vasculosus, 638 

verrucosus, 523 
Ncevus lichenoide, 523 
Nail, true, 50 
Nail-bed, 50 
Nail-fold, 50 
Nail-plate, 50 
Nails, 49 

atrophy of, 598 

" white spots " on, 599 
Naphtol, 108 
Narbe, 611 
Natal sore, 269 
Necrotic granuloma, 459 
Nerve-fibres, medullated, 31 
Nerves, 31 

of nose, medullated, 31 

tumor of, 621 
Nervous system, 65 
Nesselausschlag, 215 
Nessehucht, 215 
Nettle-rash, 215 
Neuralgia cutis, 806 
Neuroderma, 810 
Neurodermatitis, 810 
Neurom, 621 
Neuroma, 621 

symptoms, 621 
Neurome, 621 
Neuropathic plica, 539 
Neurotic excoriations, 139 
New-growths, 611 
Nigua, 892 

Nodositas crinium, 593 
Noli-me-tangere, 787 

OCCUPATION, 68 
Odorous emanations, 48 
(Edema, acute circumscribed, 226 
idiopathic, 226 
non-inflammatory, 226 
purulent, 274 
circumscribed, 227 
cretinoid, 819 
neonatorum, 544 
diagnosis, 545 
etiology, 545 
pathology, 545 
prognosis, 545 
symptoms, 545 
treatment, 545 
persistent, 227 
(Eil de perdrix, 511 
(Estridse, 901 
(Estrus bovis, 900 
"Ohio scratches," 818 
Oily substances, 100 
Oleates, 106 
Onychatrophie, 598 
Onychauxis, 534 

59 



Onychauxis, etiology, 536 
prognosis, 537 
symptoms, 534 
treatment, 536 
Onychia, 535 

syphilitic, 535 
Onychogryphosis, 535 
Onychomycosis, 836 

favic, 825 
Oriental button, 269 
sore, 269 

diagnosis, 270 
etiology, 270 
pathology, 270 
prognosis, 270 
symptoms, 269 
treatment, 270 
ulcer, 269 
Oroga fever, 771 
Osmidrosis, 134 
Otomycosis, 863 

PACRYDEKMATOCELE, 619 
Pachydermia, 555 

lymphangiectatica, 645 
Pacinian corpuscles, 32 
Paget's disease, 419, 799 
diagnosis, 800 
pathology, 800 
prognosis, 800 
symptoms, 799 
treatment, 800 
Palmar eczema, 423 
Panaris analgesique, 607 
Panniculus adiposus, 21 
Pannus Caroleus, 863 
Papillae, nervous, 24 
of skin, 24 
vascular, 24 
Papilloma, 522 

area elevatum, 522 
neuropathicum unilaterale, 523 
neuroticum, 522 
Papula?, 54 
Papules, 54 
Papulo-tubercles, 56 
Papulose filarienne, 896 
Paresthesia, 808 
Parakeratosis, 73 
scutularis, 505 
variegata, 344 
Parange, 769 
Parapsoriasis guttata, 345 

lichenoides, 345 
Parasitdre bartfinne, 848 
Parasites, animal, 881 
Parasitic affections, 823 

diseases, 70 
Paratuberculoses, 679 
Paronychia, 535 
Pars papillaris, 23 
reticularis, 22 
Paste, Bassorin's, 104 
Lassar's, 101 

Duhring's modification, 102 
pencils, 106 s 



930 



INDEX. 






Pastes, 101 

Pathology, general, 71 

Pediculi, transmission of, from man to 

animals, 910 
Pediculosis, 902 
capillitii, 902 

diagnosis, 904 
treatment, 904 
corporis, 905 

diagnosis, 907 
treatment, 908 
pubis, 908 

diagnosis, 909 
treatment, 909 
vestimenti, 905 
Peitschenwurm, 894 
Pelade, 576 

Peliosis rheumatica, 483 
Pellagra, 213 

diagnosis, 214 
etiology, 214 
pathology, 214 
prognosis, 215 
symptoms, 213 
treatment, 214 
Pemphigus, 302, 462 

diagnosis, 474 
pathology, 472 
prognosis, 476 
symptoms, 463 
treatment, 475 
acutus, 463 

contagiosus adultorum, 284 
benignus, 466 
chloraticus, 469 
chronicus, 465 
circinatus, 302, 466 
contagiosus, 465 

neonatorum acutus, 465 
disseminatus, 466 
diutinus, 465 
epidemicus, 465 
foliaceus, 467 
gangrsenosus, 249 
hsemorrhagicus, 466 
hystericus, 304 
inherited, 468 
malignus, 466 
of mucous surfaces, 470 
of young girls, 469 
neonatorum, 465 
solitarius, 466 
syphiliticus, 716 
vegetans, 469 
virginum, 469 
vulgaris, 465 
Pemphigus aigu prurigineux, 302 

compose, 302 
Pemphigus-like dermatitis, fatal, 302 
Perforating granuloma of thigh, 271 
ulcer of foot, 605 

diagnosis, 607 
pathology, 606 
prognosis, 607 
symptoms, 605 
treatment, 607 



Perical, 865 
Perifolliculitis, 290 

conglomerate pustular, 290 
Periodic swelling, 226 
Perleche, la, 862 
Pernio, 199, 234 
Peruvian wart, 769, 771 
Petechia?, 482 
Petite verole, 176 
Phagedena tropica, 272 
etiology, 272 
pathology, 272 
symptoms, 273 
treatment, 274 
Phagedena, tropical, sloughing, 272 
Phagedenisme des Pays Chauds, 272 
Phenol-camphor, 110 
Phlegmon, diffuse, 274 

progressive, 257 
Phlegmone diffusa, 274 
prognosis, 274 
treatment, 274 
Phlyctense, 56 
Phlyctenule, 56 
Phosphorescent sweat, 138 
Phosphoridrosis, 139 
Phosphorus, 95 
Phototherapy, 117 
Phtheiriasis, 902, 905 
Phthiriase, 902 
Phymata, 56 
Physiological crises, 66 
Physiology of skin, 17 
Pian dartre, 770 

gratelle, 770 

rubo'ide, 589 
Pick's tragacanth varnish, 393 

varnish, 104 
Piebald skin, 565 
Pied de Madure, 865 
Piedra, 597 

diagnosis, 597 
etiology, 597 
pathology, 597 
treatment, 597 

nostras, 598 
Pigment, 35 
Pigmentary mole, 523 

syphilide, 705 

tuberculide, 682 
Pill, Asiatic, 92 
Pilocarpine, 95 
Pinta, 863 

diagnosis, 864 

etiology, 864 

pathology, 864 

symptoms, 863 

treatment, 865 
Pinto cute, 863 
Pita, 854 
Pityriasis capitis, 573 

circinata, 329 

et marginata, 835 

lichenoides chronica, 344 

maculata et circinata, 329 

nigricans, 136 



INDEX. 



931 



Pityriasis pilaris, 494 
rosea, 329 

diagnosis, 330 
etiology, 330 
pathology, 330 
symptoms, 329 
treatment, 321 
rubra, 336 

diagnosis, 338 
etiology, 338 
pathology, 338 
prognosis, 339 
symptoms, 336 
treatment, 339 
pilaris, 339 

diagnosis, 341 
etiology, 341 
pathology, 341 
prognosis, 342 
symptoms, 339 
treatment, 342 
tabescentium, 144 
versicolor, 856 
Pityriasis circine et margine, 329, 835 
rose de Gibert, 329 
rubra aigu, 36 
pilaire, 339 
Plantar eczema, 423 
Plantaria, 209 
Plaque muqueuse, 710, 723 
Plaques blanches de la bouche, 634 

jaundtres des paupieres, 623 
Plasma-cells, 74 
Plaster-mulls, 105 
Plasters, 105 
Plate-cells, 74 
Plica polonica, 539 
Pocken, 176 
Pocks, 176 
Podelcoma, 865 
Poison ivy, 230 
Polls accidentels, 537 
Poisons, animal, 268 
Poliosis, 568 
Poliothrix, 568 
Polyidrosis, 125 
Polypapilloma tropicum, 769 
Polytrichia, 537 
Pomphi, 54 
Pompholyx, 306, 462 
diagnosis, 308 
etiology, 307 
pathology, 308 
symptoms, 307 
treatment, 308 
Pon de Birs, 901 
Pore, sweat-, 45 
Porokeratosis, 505 
Porrigo contagiosa, 284 
decalvans, 576 
favosa, 823 
larvalis, 284 
Post-mortem tubercle, 658 
Potassium permanganate, 110 
Poultices, 106 
Powders, 105 



Pox, 693 
Prairie itch, 817 

prognosis, 818 
treatment, 818 
Precautions in tinea favosa and tinea 

trichophytina, 853 
Prickle layer, 26 
" Prickly heat," 427 
Prognosis, general, 87 
Progressive phlegmon, 257 
Protozoa, 913 

Protozoic infection of skin, 881 
Prurigo, 435 

diagnosis, 438 
etiology, 437 
pathology, 438 
prognosis, 437 
symptoms, 436 
treatment, 438 
agria, 436 
ferox, 435 
gravis, 435 
of Hebra, 435 
hiemalis, 817 
mitis, 436 
summer, 478 
winter, 817 
Prurigo dermanyssique, 910 
,809 

diagnosis, 812 
etiology, 811 
pathology, 812 
prognosis, 817 
symptoms, 809 
treatment, 813 
ani, 810 
genitalium, 810 
hiemalis, 810, 817 
linguae, 811 
narium, 810 
palmse et plant*, 811 
senile, 810 
Pseudo-atheroma, 161 
Pseudo-pelade, 586 
Pseud o-xanthoma elasticum, 625 
Psora, 308 

Psoriasiform dermatoses, 344 
pathology, 346 
treatment, 347 
Psoriasis, 308 

diagnosis, 316 
etiology, 313 
pathology, 314 
prognosis, 328 
symptoms, 308 
treatment, 318 
circinata, 309 
diffusa, 309 
discoidea, 309 
figurata, 309 
follicularis, 309 
guttata, 309 
gyrata, 309 
inveterata, 309 
lingua?, 311, 634 
nummularis, 309 



932 



INDEX. 



Psoriasis of tongue, 530 
orbicularis, 309 
ostreacea, 312 
punctata, 309 
rupioides, 312 
verrucosa, 312 
Psorosperme folliculaire vegetante, 489 
Psorospermosis, 498, 913 
Pubic louse, 908 
Puce commune, 893 

sable, 892 
Pulex irritans, 893 

treatment, 893 
penetrans, 892 

treatment, 892 
Punaise des lits, 911 
Purpura, 481 

etiology, 485 
pathology, 485 
prognosis, 486 
symptoms, 482 
treatment, 486 
arthritic, 483 
fulminans, 484 
haemorrhagica, 484 
pulicosa, 482 
rheumatica, 483 
scorbutica, 484 
simplex, 482 
urticans, 483 
urticata, 216 
Pustular, 56 

Pustule, malignant, 264 
Pustule, maligne, 264 
Pustules, 56 

Pyodermite vegetante, 471 
Pyoktanin-blue, 110 
Pyrogallol, 109 
Pyroplasmosis hominis, 211 
etiology, 211 
pathology, 212 
prognosis, 212 
treatment, 212 

QUININE, 94 
Quinquaud's disease, 586 
(guinea, 863 

fiADEZYGE, 693 

Radiotherapy, 114 
Kaynaud's disease, 251 
Eecurrent summer eruption 477 
" Bed gum," 131 
Relaxed skin, 619 
Kesistant maculo-papular scaly erythro- 

dermias, 344 
Resorcin, 95, 108 
Rete Malpighianum, 26 

Malpighii, 26 

mucosum, 26 
" Rete-pegs," 23 
Rhagades, 59 
Rheumatismus febrilis, epidemicus, 209 

exanthematosus, 209 
Rhinoscleroma, 651 

diagnosis, 652 



Rhinoscleroma, etiology, 651 

pathology, 651 

prognosis, 652 

symptoms, 651 

treatment, 652 
Rhipicephalus annulatus, 901 
Rhynocoprion penetrans, 892 
Ringed eruption of extremities, 355 
Ringworm, 831 

Bowditch Island, 854 

Burmese, 854 

Chinese, 854 

disseminated, 842 

honeycomb, 823 

India, 854 

of beard, 275, 848 

of body, 833 

of scalp, 840 

scaly, 854 

scrofulous, 683 

Tokelau, 854 
Risipola Lombarda, 213 
Rochard's salve, 328 
Rocky Mountain fever, 211 
Rodent ulcer, 786, 787 
Root of hair, 40 
Root-sheaths of hair, 39 
inner, 39 
outer, 39 
Rosacea, 453 

acuminata, 454 
Rosalia, 165 
Roseola, epidemic, 169 

infantilis, 196 

leprous, 759 

scarlatiniforme, 197 

syphilitica, 702 

variolous, 176 
Rose-rash, 193 
Rotheln, 169 

diagnosis, 170 

etiology, 170 

pathology, 170 

symptoms, 169 

treatment, 170 
Rothe Schwindfiechte, 347 
Rothkleie, 336 
Rothlauf, 252 
Rotzkrankheit, 266 
Rougeole, 165 
Rouget, 898 
Rubella, 169 
Rubeola, 165 

diagnosis, 168 
etiology, 167 
pathology, 168 
prognosis, 169 
symptoms, 165 
treatment, 169 

notha, 169 
Rubeole, 169 
Rumex ointment, 451 
Rupia escharotica, 249 

SACCHAROMYCOSIS hominis, 873 
Salicylic acid, 108 



INDEX. 



933 



Salol, 94 

Salve muslins, 105 

pencils, 106 
Sand flea, 892 
Sandfloh, 892 
Sapo mollis, 99 
viridis, 99 
Sarcoid growths, 782 

multiple benign, 784 
Sarcoma cutis, 780 

diagnosis, 785 
etiology, 784 
pathology, 784 
prognosis, 786 
symptoms, 780 
treatment, 786 
idiopathic multiple pigment, 782 
melanotic, 780 
mucosum, 555 
primary, non-melanotic, 781 
Sarcomatosis cutis, 783 

generalis, 773 
Sarcophila Wohlforti, 901 
Sarcopsylla Westwood, 892 
Sarmes, 272 
Sarnes, 272 
Sartian disease, 769 
Satyriasis, 755 
Savill's disease, 342 
Scabies, 882 _ 

diagnosis, 888 
etiology, 887 
pathology, 887 
prognosis, 892 
symptoms, 882 
treatment, 889 
Scales, 57 
Scaly patches, 724 
Scar, 611 
Scar-keloid, 613 
Scarf-skin, 25 
Scarlatina, 171 

diagnosis, 175 
etiology, 174 
pathology, 174 
prognosis, 175 
sequels of, 172 
symptoms, 171 
treatment, 173 
anginose, 173 
anomalies of, 172 
complications of, 172 
septic, 173 
toxic, 173 
treatment, 175 
Scarlatine, 171 

foudroyanle, 173 
Scarlatiniform typhus, 173 
Scarlatinoid erythema, 197 
Scarlatinoi'de, 197 
Scarlet fever, 171 
rash, 171, 197 
Scars, 60 
Scharlach, 171 
Scheerende flechte, 833, 840 
Scheme for examination of patients, 84 



Schleimhaut papeln, 723 
Schmeerfluss, 140 
Schonlein's disease, 483 
Schuppenflechte, 308 
Schwammformige, 769 
Sclerema adultorum, 547 

of newborn, 546 
Sclereme des nouveaux-nes, 546 
Scleriasis, 547 
Scleroderma, 547 

diagnosis, 553 
etiology, 552 
pathology, 552 
prognosis, 554 
symptoms, 547 
treatment, 554 
alba, 550 
atrophica, 550 
circumscribed, 549 
diffuse symmetrical, 547 
lardacea, 550 
maculosa, 550 
neonatorum, 546 
nigra, 550 
plana, 540 
Sclerodermic, 547 
Scleronychia, 535 

Sclerotising granuloma of pudenda, 271 
Scratching, 67, 369 
Scrofulide erythemateuse, 683 
Scrofuloderm, ulcerative, 773 
Scrofuloderma, 662 

verrucosum, 659 
Scrofuloma, 662 
Scrofulous ringworm, 683 
Scurvy, 484 

land, 484 
Seasons, 68 
Sebaceous cyst, 161 
cystic disease, 163 
flux, 140 
glands, 42 

diseases of, 140 
hypertrophy of, 160 
secretion, 43 
tumor, 161 
Seborrhagia, 140 
Seborrhee, 140 

depilante, 111 
Seborrhoea, 140 

diagnosis, 146 
etiology, 144 
pathology, 145 
prognosis, 152 
symptoms, 140 
treatment, 147 
congestiva, 683 
corporis, 431 
flower-leaf type, 143 
lichenoides, 431 
of evelids, 143 
of face, 143 
of genitals, 143 
of umbilicus, 143 
oleosa, 140 
papulosa, 431 



934 



INDEX. 



Seborrhea petaloides, 143 

sicca, 141 

simplex, 140 

squamosa neonatorum, 144 

waxy, 142 
Senile alopecia, 571 

atrophy of skin, 600 
Sensory dermatoneuroses, 855 
Septic scarlatina, 173 
Septum lucidum, 28 
Serampion, 165 

Serpiginous ulceration of genitals, 271 
Sex, 65 

Sexual system, 66 
Shedding of skin, 198 
Shingles, 295 
SijUide, 693 
Sifilis, 693 
Simulia, 912 
Sirop de Gibert, 745 
Skin, anatomy of, 17 

atrophy of, 600 

development of, 19 

eruptions in pregnancy, peculiar, 302 

lax, 619 

physiology of, 17 

relaxed, 619 

true, 21 
Skin-plate, 19 
Slipada, 865 
Small-pox, 176 

black, 180 

eruption, 177 
Smokers' patches, 311 

of mouth, 634 
" Snuffles," 726 
99 

hard, 99 

medicated, 100 

over-fatty, 100 

soft, 99 
Soft warts, 618 
Solar heat, 67 

light, 67 
Sommersprosse, 487 
Spargosis fibro-areolaris, 555 
Spedalkshed, 753 
Sphaceloderma, 248 
" Spider cancer," 639 
Spiritus saponis alkalinus (of Hebra), 99 
Spitzblattern, 186 
Spitzencondylom, 515 
Spitzenwarze, 515 
Splenic fever carbuncle, 264 
Sporozoa, 913 
Spots, 53 
Spotted disease of Central America, 863 

fever, 211 

sickness, 863 
Spraying, 96 
Squamse, 57 
St. Anthony's fire, 252 
Stains, 53 

Staphylococcia, 283 
Startin's acid mixture, 446 
Startin's lotion, 390 



Startin's mixture, 147 
Steatoma, 161 

diagnosis, 162 

pathology, 162 

prognosis, 163 

symptoms, 161 

treatment, 162 
Stealome, 161 
Steatorrhea, 140 

nigricans, 136 

simplex, 140 
Steatozoon, 892 
Stigmata, bleeding, 139 
Stili dilubiles, 106 

unguentes, 106 
Stinkender schweiss, 134 
Stinking sweat, 134 
Stomaxis calcitrans, 901 
Stratum corneum, 20 

disjunctum, 29 

filamentosum, 27 

germinativum, 27 

granulosum, 27 

intermedium, 28 

lucidum, 28 

mucosum, 26 

subcutaneum, 20 
Strophulus, 131 

albidus, 158 
Subcutaneous injections in syphilis, 742 

tissue, 20 
Sudamen, 129 

diagnosis, 130 

etiology, 130 

pathology, 130 

symptoms, 129 

treatment, 130 
Sudatoria, 125 
Sudor sanguineus, 139 
Sudoriparous fat-cells, 161 

glands, 44 
Suette miliaire, 131 
Sulphur, 109 

baths, 98 

internally, 95 
Summer eruption, recurrent, 477 

prurigo, 478 
Sunburn, 489 
Superfluous hair, 537 
Suppurative tubercular lymphangiectasis, 

663 
Surgical operations, 111 

appliances, 111 
" Swamp itch," 818 
Sweat, 47 

bloody, 139 

colored, 136 

fetid, 134 

phosphorescent, 138 

stinking, 134 
Sweat-glands, 44 

adenoma of, 633 

diseases of, 125 
Sweating sickness, 131 
Sycose, 275 
Sycosiform dermatosis, 275, 277 



INDEX. 



935 



Sycosis, 275 

bacillogenous, 275 
coccogenous, 275 
diagnosis, 279 
etiology, 278 
pathology, 278 
prognosis, 282 
symptoms, 275 
treatment, 280 
framboesiformis, 589 
hyphogenous, 275, 848 
lupoid, 585 
non-parasitic, 275 
nuchse necrotisans, 589 
parasitica, 848 
staphylogenes, 275 
vulgaris, 275 
Sycosis papillomateux, 589 
Symmetrical gangrene of extremities, 237 

keratodermia of extremities, 501 
Symmetry in skin diseases, 80 
Symptomatology, general, 52 
Symptoms, objective, 52 

subjective, 52 
Synanthemata, 61 
Synovial lesions of the skin, 522 
Syphilides, 698 
macular, 702 
palmar, 710 
pigmentary, 705 
plantar, 710 
varicelliform, 712 
Syphilis, 693 

diagnosis, 733 
etiology, 730 
pathology, 731 
prognosis, 750 
symptoms, 694 
treatment, 735 
benignant, 694 
malignant, 694 
of mucous membranes, 723 
Syphilitic roseola, 702 
Syphiloderm, circinate tubercular, 717 
echthymaform, 716 
impetigoform, 715 
pustulo-ulcerativum, 716 
Syphiloderma acquisitum, 725 
bullosum, 716 
gummatosum, 720 
hsereditarium, 725 
infantile, 725 
maculosum, 702 

due to hyperemia, 702 
due to pigment anomaly, 705 
papular, 706 

acuminate, large, 708 

small (miliary), 707 
flat, large, 708 
small, 708 
papulosum, 706 
pustular, 713 

(acneiform, varioloform), 714 
acuminate, large, 714 

small (miliary), 714 
flat, large, 716 



Syphiloderma, pustular, flat, small, 715 

pustulosum, 713 

tuberculosum, 717 

serpiginosum, 717 

vesiculosum, 712 
Syphilodermata, 698 

general characters of, 699 
Syringo-cysta denome, 633 
Syringomyelia, 607 

fACHE PIGMENTAIRE, 523 
Taches bleudtres, 910 
ombrees, 910 
Tactile corpuscles, 33 
" Tanning," 489 
Tar, 95 

acne, 326 
baths, 99 
Taschkat ulcer, 296 
Taschkent-Geschwur, 769 
Tattooing, 49 
Taurine, 96 
Teigne faveuse, 823 
tondante, 840 
Telangiectasis, 639 

faciei, 453 
Terms descriptive of lesions, list of, 61 
Tetia, 769 

" Texas mange," 818 
Therapeutics, general, 89 
Thermal changes, 67 
Thiol, 108 
Thiosinamine, 96 
Thyroid extract, 95 
Tick fever, 211 
Tinea barbae, 848 
circinata, 833 

diagnosis, 837 
etiology, 836 
pathology, 836 
prognosis, 840 
symptoms, 833 
treatment, 837 
decalvans, 576 
favosa, 823 

diagnosis, 828 
etiology, 825 
pathology, 826 
prognosis, 830 
symptoms, 823 
treatment, 828 
imbricata, 854 
diagnosis, 855 
etiology, 855 
pathology, 855 
prognosis, 855 
symptoms, 854 
treatment, 855 
kerion, 847 
nodosa, 598 
sycosis, 848 

diagnosis, 851 
etiology, 849 
pathology, 850 
prognosis, 853 
symptoms, 845 



936 



INDEX. 



Tinea sycosis, treatment, 852 
tondens, 840 
tonsurans, 840 

diagnosis, 844 
etiology, 842 
pathology, 843 
prognosis, 847 
symptoms, 841 
treatment, 845 
" bald," 842 
trichophytina, 831 
cruris, 835 
unguium, 836 
tropica, 854 
versicolor, 856 

diagnosis, 859 
etiology, 857 
pathology, 858 
prognosis, 860 
symptoms, 856 
treatment, 859 
Tinna, 863 
Tique, 901 
Toboe, 769 

Tokelau ringworm, 854 
Tomo, 769 
Tonga, 769 

" Tonic treatment" of syphilis, 739 
Touch-cells, 34 
Toxic scarlatina, 173 
Toxirtuberculides, 679 
Trade eczemas, 423 
Tragacanth varnish, 395 
Traumaticin, 106 
Traumatism, 69 
Treatment, external, 97 

internal, 91 
Trichauxis, 537 
Trichiasis, 539 
Trichoclasia^ 593 
Trichomycosis nodosa, 596 

palmellina, 596 
Trichonosis cana, 568 
Trichophytie, 833 

sycosigue, 848 
Trichophyton, 836 
Trichoptilosis, 593 
Trichorrhexis nodosa, 593 
etiology, 594 
pathology, 594 
treatment, 594 
Tropical sloughing phagedena, 272 
Tropische phagedanismus, 272 
Tubercle, anatomical, 658 
dissection, 658 
post-mortem, 658 
Tubercles, 55 
Tubercula, 55 

Tuberculide, pigmentary, 682 
Tuberculides, 679 
Tuberculin, 96 
Tuberculosis cutis, 653 

diagnosis, 668 
etiology, 664 
pathology, 665 
prognosis, 676 



Tuberculosis cutis, symptoms, 653 
treatment, 670 

by Finsen's method, 670 
miliary exanthematic, 661 
orificialis, 661 
serpiginosa ulcerativa, 664 
verrucosa, 658 
fungosa cutis, 660 
papillomatosa cutis, 660 
verrucosa cutis, 659 
Tuberculous dactylitis, 663 

eczema of nurslings, 365 
Tuberculum sebaceum, 158 
Tuberose carcinoma, 802 
Tumor cavernosus, 640 
Tumors, 56 
Turpentine, 95 
Tylosis linguae, 634 
Tysonian glands, 43 

ULCER, Aden, 272 
cancroid, 787 
Cochin China, 272 
" crateriform," 788 
genital, 271 
Jacob's, 787 
Mozambique, 272 
of groin, 271 
oriental, 269 
rodent, 787 
Taschkat, 269 
Yemen, 272 
Ulcera, 59 

Ulcerating granuloma of the pudenda, 271 
diagnosis, 272 
etiology, 272 
pathology, 272 
symptoms, 271 
treatment, 272 
Ulcerative scrofuloderm, 773 
Ulcere endemique, 272 

phagedenique des pays chauds, 272 
Ulcers, 59 
Ulcus exedens, 787 

grave, 865 
Ulerythema acneiforme, 443 
centrifugum, 683 
ophryogenes, 590 
sycosiforme, 275, 277, 585 
Uridrose, 138 
Uridrosis, 138 
Urtica dioica, 217 

urens, 217 
Urticse, 54 
Urticaire, 215 
Urticaria, 215 

diagnosis, 219 
etiology, 217 
pathology, 218 
prognosis, 223 
symptoms, 215 
treatment, 220 
ab ingestis, 217 
annularis, 216 
bullosa, 215 
evanida, 217 



INDEX. 



937 



Urticaria figurata, 215 
giant, 226 
hemorrhagica, 216 
papulosa, 215 
perstans, 217 
pigmentosa, 223 

diagnosis, 225 

etiology, 225 

pathology, 225 

symptoms, 223 

treatment, 225 
tuberosa, 215, 217 
vesiculosa, 215 
Urticarial autogram, 215 

VACCINAL eruptive fever, 192 
Vaccine, 188 
Vaccine scars, 188 
Vaccinia, generalized, 192 

pathology, 192 

treatment, 193 
hemorrhagica, 191 
Vagabonds' disease, 910 
Vajuolo, 176 
Varicella, 186 

diagnosis, 187 

etiology, 187 

pathology, 187 

symptoms, 186 

treatment, 188 
gangrenosa, 249 

-form syphilide, 712 
Variola, 176 

diagnosis, 183 

etiology, 182 

pathology, 182 

prognosis, 184 

symptoms, 176 

treatment, 184 
confluent, 181 
hemorrhagic, 180 
initial rashes, 176 
nigra maligna, 180 
Variolette, 186 
Varioloid, 179 
Variolous erythema, 176 

roseola, 176 
Varix lymphaticus, 557 
Varnishes, 104 
Varus, 439 
Vasogen, 106 
Venereal wart, 515 
Venerische granulom, 271 

warze, 515 
Verbunden mit kolloides degeneration, 633 
Ver du Kutegal, 894 
Vergetures, 601 
Verole, 693 
Verruca, 515 

diagnosis, 518 

etiology, 518 

pathology, 518 

prognosis, 521 

symptoms, 515 

treatment, 520 



Verruca acquisita, 516 
acuminata, 515 
congenita, 516 
digitata, 516 

dorsi manus et pedis, 517 
filiformis, 516 
glabra, 517 
necrogenica, 517, 658 
plana, 517 

juvenilis, 517 
seborrheica, 517 
senilis, 517 
vulgaris, 517 
Verrue, 515 
Vermes charnues, 618 
Verruga Peruana, 771 
diagnosis, 773 
etiology, 772 
pathology, 773 
prognosis, 773 
symptoms, 772 
treatment, 773 
Vesicles, 56 
Vesicule, 56 
Vespide, 912 
Vessels, blood-, 29 
lymphatic, 30 
Vibices, 482 
Visceral disorders, 65 
Vitiligo, 565 

diagnosis, 567 
etiology, 566 
pathology, 567 
prognosis, 568 
symptoms, 565 
treatment, 567 
acquisita syphilitica, 705 
Vitiligoidea, 623 
Vleminckx's solution, 98 

WAEKEN'S fat-columns, 21 
Wart cures, 520 
fig-, 515 
moist, 515 
Peruvian, 769, 772 
venereal, 515 
Warts, 515 

soft, 618 
Warze, 515 
Wasserpocken, 186 
Water externally given, 97 

internally given, 94 
Wen, 161 
Wheals, 54 

giant, 55, 215 
Whiteness of hand, 568 
" White spots " in nails, 599 
Whitlow, 535 
Wilkinson's salve, 327 
Winter prurigo, 817 
Wood-tick, 901 
Wool-fat, 106 
Wounds, dissection, 268 
insect, 268 
reptile, 268 



938 



INDEX. 



XANTHELASMA, 623 
Xanthelasmoidea, 223 
Xanthoma, 623 

diagnosis, 627 
etiology, 625 
pathology, 626 
prognosis, 627 
symptoms, 623 
treatment, 627 

diabeticorum, 628 
diagnosis, 629 
etiology, 628 
pathology, 629 
prognosis, 629 
symptoms, 628 
treatment, 629 

elasticum, 625 

glycosuric, 628 

multiplex, 624 

planum, 623 

solitarium, 625 

tuberculatum, 624 

tuberosum, 624 
Xeroderma pigmentosum, 647 
diagnosis, 650 
etiology, 649 
pathology, 650 
prognosis, 630 
symptoms, 647 
treatment, 650 
Xeroderme, 527 



Xerodermia, 527 
Xerosis, 152, 527 
AT-ray apparatus, 115 

dermatitis, 247 

technique, 116 

treatment, 114 

tubes, 116 
X-rays, 68 

action of, 115 

YAWS, 769 
caeca, 770 
u crab," 770 
"guinea-corn," 770 
" ringworm," 770 
tubercle, 770 

ZONA, 295 

^ Zoster, 295 

abdominalis, 298 
brachialis, 297 
capillitii, 297 
collaris, 297 
facialis, 297 
femoralis, 298 
frontalis, 297 
hsemorrhagicus, 296 
nucha?, 297 
ophthalmicus, 297 
pectoralis, 297 



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PLAYFAIR (W. S.). THE SCIENCE AND PRACTICE OF MIDWIFERY. 

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SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMATOLOGY. 

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